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HAND
EVALUATION
BY AMRIT KAUR
♦Hand function is an
important feature in
humans over other
primates who lack
fine control and
precision
Bony
Anatomy
♦ Phalanges: 14
♦ Sesamoids: 2
♦ Metacarpals: 5
♦ Carpals
– Proximal row: 4
– Distal row: 4
♦ Radius and Ulna
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
Is it bone?
Is it nerve?
Is it the ligaments or joints?
Is it muscle or tendon?
HISTORY
♦ Age
♦ Handedness
♦ Chief complaint
♦ Occupation
♦ Previous injury
♦ Previous surgery
♦ Sx related to specific
activities
♦ What exacerbates
♦ What improves
♦ Frequency
♦ Duration
♦ Which part of hand is injured.
♦ Flexor tendon respond much more slowly to
treatment than extensor tendon .
♦ Within hand there is surgical no man’s land,
which is a region between the distal palmar
crease and mid portion of middle phalanx of
the finger.
♦ Damage in this area require surgical repair
and usually leads to formation of adhesive
bands that restrict gliding.
Red Flags
♦ This section deals with screening the patient for
possible serious pathologies that could cause wrist
or hand pain. These conditions could warrant a
referral, or consultation.
Infections
♦ Heat
♦ Swelling
♦ Pain
♦ Redness
♦ Inflammation
Fracture/dislocation:
♦Top five physical findings which are most
useful in screening for wrist fracture.
♦Localized tenderness
♦Pain on active motion
♦Pain on passive motion
♦Pain on grip
♦Pain on supination
♦Bottom line: Any one of the above findings
associated with a history of trauma should be
sent for radiographs
OBSERVATION
– Wrist “attitude”
• How do the carpals and metacarpals align with
the distal radius and ulna?
• Is there symmetry?
– Deformities , swelling, Muscle girth or presence of
atrophy.
♦ Posture -During the posture examination the physical
therapist should examine from the lateral, posterior,
and anterior views looking at the position of the
cervical and thoracic spine along with the shoulder,
elbow, forearm, wrist, and hand.
♦ Carrying angle
♦ Shoulder height
PALMAR SURFACE
♦ Creases
♦ Thenar and
Hypothenar
Eminence
♦ Arched Framework
♦ Hills and Valleys
♦ Web Spaces
Cascade sign
♦ Assure all fingers
point to scaphoid
area when flexed
at PIPs
Dorsal Hand and Wrist
♦ Height of metacarpal heads
♦ Finger nails
– Pale or white=anemia or circulatory
– Spoon shaped=fungal infection
– Clubbed=respiratory or congenital heart
Common hand and finger
deformities
♦ Swan neck deformity
♦ Boutonniere deformity
♦ Ulnar drift
♦ Extensor plus
deformity
♦ Claw fingers
♦ Trigger finger
♦ Ape hand deformity
♦ Bishop’s hand or
benediction hand
deformity
♦ Drop wrist deformity
♦ Myelopathy hand
♦ Z deformity of the
hand
♦ Dupuytrens
contracture
♦ Mallet finger
Palpation
– Bony and Soft Tissue Palpation
• Are they where they should be?
• Do they feel like they should feel?
– Circulatory and Neurological Evaluation
• Hands should be felt for temperature
– Cold hands indicate decreased circulation
• Take pulse – radial artery
• Pinching fingernails can also help detect circulatory
problems (capillary refill)
• Hand’s neurological functioning should also be
tested (sensation and motor functioning)
Range of motion
♦ The available arc of movement within a joint
which can be classified into:
♦ Active range of motion (AROM)
♦ Passive range of motion (PROM)
♦ Total active range of motion (TAROM), also
known as total active motion (TAM)
♦ Total passive range of motion (TPROM), also
known as total passive motion (TPM)
♦ Torque range of motion (TROM)
♦ TAROM or TAM-Defined as the total ROM
achieved when all three joints—
metacarpophalangeal (MCP), proximal
interphalangeal (PIP) and distal
interphalangeal (DIP) of a digit are actively
flexed or extended simultaneously, minus
any extension deficit at any of the three
joints.
♦ TPROM or TPM-Analogous to TAROM,
however this measurement is achieved
through passively moving the joint.
♦ TROM-Refers to a joint being moved
passively through its full available ROM with
a known constant force applied.
Standard position for
measuring
♦ For finger and wrist measurements, position
the elbow on a table at 90° and wrist in
neutral.
♦ For elbow pronation and supination, tuck arm
into trunk with the forearm in mid position.
Instruments
♦Goniometer
♦Ruler/tape measure
♦Fluid goniometer
♦MULE (microprocessor upper limb
exerciser)—used as an assessment and
rehabilitation tool
Muscle testing
Weakness or disappearance of voluntary
movement may be due to:
♦Failure of the afferent nerve
♦Destruction of muscle tissue
♦Ischemia
♦Tendon rupture
♦Tendon adhesions
Measurement
♦Manual muscle testing
♦Grip strength
♦Pinch grip
To test muscle power accurately the examiner must be
familiar with the
♦anatomy of the hand and arm, particularly:
♦Origins and insertions of muscles
♦The general direction and line of pull of each muscle
♦The relative positions of muscle and tendons
♦Nerve supply and possible anomalies
♦Possible trick movements
Indications
♦Peripheral nerve lesions
♦Tendon transfers
♦Neuromuscular conditions
Contraindications
♦Where movement or the application of
resistance is not recommended (e.g. healing
phase of tendon repair)
Method of administration
♦Ensure the patient is positioned appropriately
♦Ensure that the part proximal to the tested part
is stabilized
♦Select the muscle and joint movement
required:
♦Check that the PROM is normal/expected
♦Demonstrate to the patient what is expected
OBSERVE:
♦Movement at the joint
♦Any contraction of the muscle belly and
tendon
Palpate:
♦Muscle contraction
♦Record muscle power:
♦Ensure that the placement of the hand
applying pressure is uniform
♦Apply pressure directly opposite the line of
pull of the muscle being tested
♦Apply pressure gradually
Factors that can affect accuracy include
♦Pain
♦Swelling
♦Joint mobility/ROM
♦Sensory loss
Advantages
♦No equipment required
♦Inexpensive
♦Quick to administer
Functional assessment
♦ In terms of functional impairment the loss
of thumb function affect 40 % to 50 % of
hand function.
♦ Loss of index finger and middle finger
function account for 20% of hand function,
loss of ring finger and little finger function
affect 10% of hand function.
♦ Loss of hand account for about 90% loss of
upper limb function.
Function
♦ Hand function tests typically fall into two
categories:
♦ Norm-referenced tests-Objective grading
systems are used, mainly time as the critical
measure of hand function. Researchers favour
them, as they are quick and easy to administer
and produce objective data.
♦ Criterion-referenced tests- Descriptive
standards are used to measure a patient’s
performance. They need an experienced person
to interpret the results and to achieve
consistency with scoring.
♦ Normally wrist is held in slight extension
(10-15 degree) and slight ulnar deviation
and is stabilized in this position to provide
maximum function for finger and thumb.
♦ Excessive radial deviation can affect grip
strength adversely.
♦ Flexion and sensation of ulnar digits are
controlled by ulnar nerve and are more
related to power grip.
♦ Flexion and sensation of radial digits are
controlled by median nerve and more
related to precision grip.
♦ The muscle of the thumb often used in both
types of grips are supplied by both nerves.
♦ In all cases of grip opening, opening of
hand, or release of grip depends on radial
nerve.
Power grip
Indicator of hand function is measured by
isometric grip.
Indications
♦To establish a baseline for treatment
♦To monitor progress
♦To establish final outcome.
Contraindications
♦Less than 12 weeks after tendon repair or
transfer
♦Excessive pain
♦Patients with active inflammatory disease.
Tools
♦Jamar dynamometer
♦Vigorimeter
Vigorimeter
♦ Measures grip strength using air pressure.
Three different-sized rubber bulbs attached
via a tube to a manometer. Possibly more
comfortable to use than the Jamar
dynamometer and due to the ability to vary
the sizes, may be better suited for children.
Types
♦Hook grip
♦Cylinder grip
♦Fist
♦Spherical
Pinch grip or precision grip
Provides a good indication of thumb function.
Three different types:
♦pure (otherwise known as tip pinch)
♦Tripod ( chuck or three fingered pinch)
♦key (otherwise known as lateral pinch)
Tools-pinch gauges
Contraindications
♦Early tendon repairs
♦Early repairs of collateral ligaments
♦First 8 weeks after trapeziectomy
♦Excessive pain
♦Inflamed joints
♦ Tip pinch grip-The thumb is pinched
against the pulp of the index finger whilst
the other fingers are flexed.
♦ Tripod pinch grip-Thumb pulp to index
and middle finger pulp with remaining
fingers flexed.
♦ Key pinch grip-Thumb pulp to lateral
aspect of proximal interphalangeal joint of
the index finger, other fingers flexed
Tests for dexterity and function
♦ Moberg
♦ Nine-hole peg test
♦ Purdue pegboard
♦ Minnesota Rate of Manipulation Test
♦ The Serial Occupational Dexterity
Assessment (SODA)
Other functional outcome
measure
♦ Michigan hand outcome questionnaire.
♦ Functional status scale for hand
♦ Simulated activities of daily living
examination
♦ Sollerman Hand Function Test
♦ Jebsen Hand Function Test
Oedema
oedema is measured to:
♦Establish baselines for comparison
♦Evaluate a patient’s response to treatment
♦Monitor the course of a disease process
Tools
♦ Tape measure-Advantages: quick to use,
cheap to purchase and able to provide
information regarding specific segments.
Accuracy and reliability can be improved by:
♦ Calibration of tape measures
♦ Measure over anatomical landmarks
♦ Jeweller’s rings-Used to measure the
circumference of joints. A range of
different-sized jewellers rings are placed
over the joints. Quick and easy to use,
however expensive to purchase and only
allow small joints to be measured
♦ Volumeter -Based on the Archimedes
principle: ‘A body partly or completely
immersed in a fluid displaces an amount of
fluid equal to the apparent volume of that
body.’
Sensory testing
Types of sensory dysfunction
♦Hypoaesthesia: diminished sensation
♦Parasthesia: abnormal sensation
♦Hyperaesthesia: abnormal sensation
♦Anaesthesia: complete loss of sensation
Purpose of sensory testing-
♦To assist in diagnosis
♦To determine the extent of sensory loss
♦To determine the level of axonal regeneration
(provocative tests, e.g.Tinel’s percussion test)
♦To evaluate nerve conduction efficiency
(threshold tests, electrophysiological tests)
♦To evaluate end organ unity/function
♦ To determine level of somatosensory
reorganization (ability to interpret stimuli)
♦ To identify the need for surgical
intervention
♦ To identify splinting requirements
♦ To determine when to commence sensory
re-education
♦ To identify level of hand function
Sensory testing is difficult due to:
♦Subjective nature of the tests
♦Technical difficulties with the tests, e.g.
vibration of the assessor’s hand during
testing, variation in the application of force
when utilizing the assessment t.ools
Indications for testing sensibility
♦Peripheral/digital nerve repair
♦Nerve compression
♦Nerve replants
♦Flaps/grafts
♦Brachial plexus injuries
♦Crush injuries
Precautions for testing sensibility
♦Underlying vascular or neuropathic disease
♦Fatigue
♦Negative attitude/poor motivation
♦Hypersensitivity/pain
Scar
♦ Burn scar index (Vancouver)
♦ Image panel assessment scale (photos)
♦ Self-rating scale for patients
♦ Non-invasive measurement of scar and skin
pliability (pneumatonometer and Derma-
Durameter)
♦ Numeric scar ratings scale (therapist
scored)

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Hand evaluation

  • 2. ♦Hand function is an important feature in humans over other primates who lack fine control and precision
  • 3. Bony Anatomy ♦ Phalanges: 14 ♦ Sesamoids: 2 ♦ Metacarpals: 5 ♦ Carpals – Proximal row: 4 – Distal row: 4 ♦ Radius and Ulna
  • 4.
  • 5.
  • 6. 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
  • 9. Is it the ligaments or joints?
  • 10. Is it muscle or tendon?
  • 11.
  • 12. HISTORY ♦ Age ♦ Handedness ♦ Chief complaint ♦ Occupation ♦ Previous injury ♦ Previous surgery ♦ Sx related to specific activities ♦ What exacerbates ♦ What improves ♦ Frequency ♦ Duration
  • 13. ♦ Which part of hand is injured. ♦ Flexor tendon respond much more slowly to treatment than extensor tendon . ♦ Within hand there is surgical no man’s land, which is a region between the distal palmar crease and mid portion of middle phalanx of the finger. ♦ Damage in this area require surgical repair and usually leads to formation of adhesive bands that restrict gliding.
  • 14. Red Flags ♦ This section deals with screening the patient for possible serious pathologies that could cause wrist or hand pain. These conditions could warrant a referral, or consultation. Infections ♦ Heat ♦ Swelling ♦ Pain ♦ Redness ♦ Inflammation
  • 15. Fracture/dislocation: ♦Top five physical findings which are most useful in screening for wrist fracture. ♦Localized tenderness ♦Pain on active motion ♦Pain on passive motion ♦Pain on grip ♦Pain on supination ♦Bottom line: Any one of the above findings associated with a history of trauma should be sent for radiographs
  • 16. OBSERVATION – Wrist “attitude” • How do the carpals and metacarpals align with the distal radius and ulna? • Is there symmetry? – Deformities , swelling, Muscle girth or presence of atrophy. ♦ Posture -During the posture examination the physical therapist should examine from the lateral, posterior, and anterior views looking at the position of the cervical and thoracic spine along with the shoulder, elbow, forearm, wrist, and hand. ♦ Carrying angle ♦ Shoulder height
  • 17. PALMAR SURFACE ♦ Creases ♦ Thenar and Hypothenar Eminence ♦ Arched Framework ♦ Hills and Valleys ♦ Web Spaces
  • 18. Cascade sign ♦ Assure all fingers point to scaphoid area when flexed at PIPs
  • 19. Dorsal Hand and Wrist ♦ Height of metacarpal heads ♦ Finger nails – Pale or white=anemia or circulatory – Spoon shaped=fungal infection – Clubbed=respiratory or congenital heart
  • 20. Common hand and finger deformities ♦ Swan neck deformity ♦ Boutonniere deformity ♦ Ulnar drift ♦ Extensor plus deformity ♦ Claw fingers ♦ Trigger finger ♦ Ape hand deformity ♦ Bishop’s hand or benediction hand deformity ♦ Drop wrist deformity ♦ Myelopathy hand ♦ Z deformity of the hand ♦ Dupuytrens contracture ♦ Mallet finger
  • 21. Palpation – Bony and Soft Tissue Palpation • Are they where they should be? • Do they feel like they should feel? – Circulatory and Neurological Evaluation • Hands should be felt for temperature – Cold hands indicate decreased circulation • Take pulse – radial artery • Pinching fingernails can also help detect circulatory problems (capillary refill) • Hand’s neurological functioning should also be tested (sensation and motor functioning)
  • 22. Range of motion ♦ The available arc of movement within a joint which can be classified into: ♦ Active range of motion (AROM) ♦ Passive range of motion (PROM) ♦ Total active range of motion (TAROM), also known as total active motion (TAM) ♦ Total passive range of motion (TPROM), also known as total passive motion (TPM) ♦ Torque range of motion (TROM)
  • 23. ♦ TAROM or TAM-Defined as the total ROM achieved when all three joints— metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) of a digit are actively flexed or extended simultaneously, minus any extension deficit at any of the three joints. ♦ TPROM or TPM-Analogous to TAROM, however this measurement is achieved through passively moving the joint.
  • 24. ♦ TROM-Refers to a joint being moved passively through its full available ROM with a known constant force applied.
  • 25.
  • 26. Standard position for measuring ♦ For finger and wrist measurements, position the elbow on a table at 90° and wrist in neutral. ♦ For elbow pronation and supination, tuck arm into trunk with the forearm in mid position.
  • 27. Instruments ♦Goniometer ♦Ruler/tape measure ♦Fluid goniometer ♦MULE (microprocessor upper limb exerciser)—used as an assessment and rehabilitation tool
  • 28. Muscle testing Weakness or disappearance of voluntary movement may be due to: ♦Failure of the afferent nerve ♦Destruction of muscle tissue ♦Ischemia ♦Tendon rupture ♦Tendon adhesions
  • 29. Measurement ♦Manual muscle testing ♦Grip strength ♦Pinch grip To test muscle power accurately the examiner must be familiar with the ♦anatomy of the hand and arm, particularly: ♦Origins and insertions of muscles ♦The general direction and line of pull of each muscle ♦The relative positions of muscle and tendons ♦Nerve supply and possible anomalies ♦Possible trick movements
  • 30. Indications ♦Peripheral nerve lesions ♦Tendon transfers ♦Neuromuscular conditions Contraindications ♦Where movement or the application of resistance is not recommended (e.g. healing phase of tendon repair)
  • 31. Method of administration ♦Ensure the patient is positioned appropriately ♦Ensure that the part proximal to the tested part is stabilized ♦Select the muscle and joint movement required: ♦Check that the PROM is normal/expected ♦Demonstrate to the patient what is expected OBSERVE: ♦Movement at the joint ♦Any contraction of the muscle belly and tendon
  • 32. Palpate: ♦Muscle contraction ♦Record muscle power: ♦Ensure that the placement of the hand applying pressure is uniform ♦Apply pressure directly opposite the line of pull of the muscle being tested ♦Apply pressure gradually
  • 33. Factors that can affect accuracy include ♦Pain ♦Swelling ♦Joint mobility/ROM ♦Sensory loss Advantages ♦No equipment required ♦Inexpensive ♦Quick to administer
  • 34. Functional assessment ♦ In terms of functional impairment the loss of thumb function affect 40 % to 50 % of hand function. ♦ Loss of index finger and middle finger function account for 20% of hand function, loss of ring finger and little finger function affect 10% of hand function. ♦ Loss of hand account for about 90% loss of upper limb function.
  • 35. Function ♦ Hand function tests typically fall into two categories: ♦ Norm-referenced tests-Objective grading systems are used, mainly time as the critical measure of hand function. Researchers favour them, as they are quick and easy to administer and produce objective data. ♦ Criterion-referenced tests- Descriptive standards are used to measure a patient’s performance. They need an experienced person to interpret the results and to achieve consistency with scoring.
  • 36. ♦ Normally wrist is held in slight extension (10-15 degree) and slight ulnar deviation and is stabilized in this position to provide maximum function for finger and thumb. ♦ Excessive radial deviation can affect grip strength adversely.
  • 37. ♦ Flexion and sensation of ulnar digits are controlled by ulnar nerve and are more related to power grip. ♦ Flexion and sensation of radial digits are controlled by median nerve and more related to precision grip. ♦ The muscle of the thumb often used in both types of grips are supplied by both nerves. ♦ In all cases of grip opening, opening of hand, or release of grip depends on radial nerve.
  • 38. Power grip Indicator of hand function is measured by isometric grip. Indications ♦To establish a baseline for treatment ♦To monitor progress ♦To establish final outcome.
  • 39. Contraindications ♦Less than 12 weeks after tendon repair or transfer ♦Excessive pain ♦Patients with active inflammatory disease. Tools ♦Jamar dynamometer ♦Vigorimeter
  • 40. Vigorimeter ♦ Measures grip strength using air pressure. Three different-sized rubber bulbs attached via a tube to a manometer. Possibly more comfortable to use than the Jamar dynamometer and due to the ability to vary the sizes, may be better suited for children.
  • 42. Pinch grip or precision grip Provides a good indication of thumb function. Three different types: ♦pure (otherwise known as tip pinch) ♦Tripod ( chuck or three fingered pinch) ♦key (otherwise known as lateral pinch) Tools-pinch gauges
  • 43. Contraindications ♦Early tendon repairs ♦Early repairs of collateral ligaments ♦First 8 weeks after trapeziectomy ♦Excessive pain ♦Inflamed joints
  • 44. ♦ Tip pinch grip-The thumb is pinched against the pulp of the index finger whilst the other fingers are flexed. ♦ Tripod pinch grip-Thumb pulp to index and middle finger pulp with remaining fingers flexed. ♦ Key pinch grip-Thumb pulp to lateral aspect of proximal interphalangeal joint of the index finger, other fingers flexed
  • 45. Tests for dexterity and function ♦ Moberg ♦ Nine-hole peg test ♦ Purdue pegboard ♦ Minnesota Rate of Manipulation Test ♦ The Serial Occupational Dexterity Assessment (SODA)
  • 46. Other functional outcome measure ♦ Michigan hand outcome questionnaire. ♦ Functional status scale for hand ♦ Simulated activities of daily living examination ♦ Sollerman Hand Function Test ♦ Jebsen Hand Function Test
  • 47. Oedema oedema is measured to: ♦Establish baselines for comparison ♦Evaluate a patient’s response to treatment ♦Monitor the course of a disease process
  • 48. Tools ♦ Tape measure-Advantages: quick to use, cheap to purchase and able to provide information regarding specific segments. Accuracy and reliability can be improved by: ♦ Calibration of tape measures ♦ Measure over anatomical landmarks
  • 49. ♦ Jeweller’s rings-Used to measure the circumference of joints. A range of different-sized jewellers rings are placed over the joints. Quick and easy to use, however expensive to purchase and only allow small joints to be measured
  • 50. ♦ Volumeter -Based on the Archimedes principle: ‘A body partly or completely immersed in a fluid displaces an amount of fluid equal to the apparent volume of that body.’
  • 51.
  • 52.
  • 53. Sensory testing Types of sensory dysfunction ♦Hypoaesthesia: diminished sensation ♦Parasthesia: abnormal sensation ♦Hyperaesthesia: abnormal sensation ♦Anaesthesia: complete loss of sensation
  • 54. Purpose of sensory testing- ♦To assist in diagnosis ♦To determine the extent of sensory loss ♦To determine the level of axonal regeneration (provocative tests, e.g.Tinel’s percussion test) ♦To evaluate nerve conduction efficiency (threshold tests, electrophysiological tests) ♦To evaluate end organ unity/function
  • 55. ♦ To determine level of somatosensory reorganization (ability to interpret stimuli) ♦ To identify the need for surgical intervention ♦ To identify splinting requirements ♦ To determine when to commence sensory re-education ♦ To identify level of hand function
  • 56. Sensory testing is difficult due to: ♦Subjective nature of the tests ♦Technical difficulties with the tests, e.g. vibration of the assessor’s hand during testing, variation in the application of force when utilizing the assessment t.ools
  • 57. Indications for testing sensibility ♦Peripheral/digital nerve repair ♦Nerve compression ♦Nerve replants ♦Flaps/grafts ♦Brachial plexus injuries ♦Crush injuries
  • 58. Precautions for testing sensibility ♦Underlying vascular or neuropathic disease ♦Fatigue ♦Negative attitude/poor motivation ♦Hypersensitivity/pain
  • 59.
  • 60. Scar ♦ Burn scar index (Vancouver) ♦ Image panel assessment scale (photos) ♦ Self-rating scale for patients ♦ Non-invasive measurement of scar and skin pliability (pneumatonometer and Derma- Durameter) ♦ Numeric scar ratings scale (therapist scored)