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Tips on upper limb assessment

This document provides guidance on upper limb assessment. It discusses examining the hand, including range of motion testing of the fingers, thumb, and wrist. It also covers muscle strength testing, tendon examination, nerve examination including sensory distribution and reflex testing, vascular evaluation, and special tests for conditions like De Quervain's disease. The overall document provides a comprehensive overview of systematically examining the upper limb.

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Tips on upper limb assessment Mr V Rajaratnam FRCS(Ed),Dip Hand Surgery (Eur) Consultant Hand Surgeon
EXAMINING THE HAND • Systems of examination. • History. • Normal - abnormal positions and movements of the hand. • Special conditions and tests. • Radiological Evaluation. • Arthroscopy - Electrodiagnosis.
HISTORY IMPORTANT QUESTIONS IN ALL CASES: •Social history (very important especially when considering operation) - professional - recreational activities. • Dominant hand. • Function of the whole upper limb - functional state of the opposite limb. • General health, known pathologies, current therapy (diabetes, rheumatoid arthritis, corticosteroid intake...) • psychological state, known allergies. • Smoking - alchohol intake. • Family history.
HISTORY PERSONALITY - INTELLIGENCE AND RELIABILITY • Meeting the surgeon’s gaze. • Honesty of the patient. • Innapropriate affect: ill defined pain. • Malingering: Glove hypaesthesia, rapid echange grip strength, distracted function. •Liability: the patient wishes to extract maximum compensation. • After taking full history most of the surgeons have concluded to d/d of only a few pathological conditions.
NORMAL POSITIONS OF THE HAND •All fingers when flexed at the MCPJ and the PIPJ point to the tubercle of the scaphoid. •Very important in assessing the normal rotation in fractures of the metacarpals and phalanges. •In rotation malalignement the «scissoring» deformity is unacceptable, both cosmetically and functionally. •Observing the plane of the fingernails helps detecting any malrotation in case of fracture - always compare with the other limb.
BASIC POSITIONS OF THE HAND • Precision pinch: The tips of fingernails of index finger and thumb are brought together. • Pulp pinch: The pulps of index finger and thumb are opposed. Normal power 5 - 10 pounds. •Key pinch: The pulp of the thumb is opposed to the radial side of the middle phalanx of the index finger. Normal power 13 - 20 pounds. •Chuck grip: The digital pulps of index and middle fingers brought into contact with the pulp of the thumb.
BASIC POSITIONS OF THE HAND • Hook grip: The fingers are flexed in the IPJ and extended in the MCPJ. •Span grasp: From the hook grip the IPJ are extended 30° and the thumb abducted fully. •Power grasp: The fingers flexed fully and the opposed thumb is flexed over the fingers to increase power. Normal 90 - 100 pounds. The normal variation is 10%, but sometimes the dominant hand is not always stronger. •Flat hand: Fingers, thumb extended, thumb adducted.
MUSCLE STRENGTH TESTING • The Jamar grip stength dynamometer. The combined efforts of the intrinsic and the extrinsic muscles are evaluated in Levels 1, 2 and 3. In Levels 4, 5 primary extrinsic muscle is evaluated. •The pinch meter. The pinch meter should be held lightly by the examiner and never fixed in any way during testing. • SCALE OF POWER: 0: Total paralysis - no contraction detectable on palpation. 1: Flicker - no movement, but contraction palpable. 2: Movement with gravity eliminated - placing the line of action of the muscle in the horizontal plane. 3: Movement against gravity. 4: Movement against gravity and resistance. 5: Full power.
EXAMINING THE HAND RANGE OF MOTION • Perform full ROM active and passive in all the fingers in both hands. • Normal: MCPJ: 0 - 90° PIPJ: 0 - 120° DIPJ: 0 - 60° Thumb IPJ: 0 - 60°. • It is not possible to flex the DIPJ of 3 - 4 - 5 fingers independently. It is very important when the fingers flex , their pulp to touch the palm.
EXAMINING THE HAND RANGE OF MOTION - THE THUMB • The 1st MCPJ (trapeziometacarpal) is functionally the most important because it allows movement of the whole column of the thumb. • There is confusion in terminology - different authors use different terms to describe thumb movements. • ABDUCTION: Seperation in the plane of the palm. • ANTEPOSITION: Seperation in a perpendicular plane to the plane of the palm. • ADDUCTION: Brings the thumb in contact with the palm • OPPOSITION: Complex movement: Anteposition and adduction of the 1st metacarpal, flexion of the MCPJ and IPJ, pronation of all the skeletal elements..
EXAMINING THE WRIST RANGE OF MOTION • Perform full ROM active and passive in both hands. • Normal: Extension: 60° Flexion: 70° Wrist radial deviation: 20° Wrist ulnar deviation: 30° Forearm supination: 80° Forearm pronation: 80°
EXAMINING THE WRIST DORSAL PALPATION • Scaphoid: just distal to the radial styloid. Its tuberosity prominent in extension - radial deviation. The waist palpable deep to the anatomic snuffbox (always examine both hands). • Trapezium: distal to the scaphoid, along the axis of the thumb. Can be distinguished from the 1st metacarpal by gently rotating the thumb. • Lunate: Prominent with the wrist flexed, ulnar to the Lister’s tubercle. • Capitate: distal to the lunate. • Hamate: proximal to the 5th metacarpal. • Distal radioulnar joint: radial to the ulnar head. • Triangular Fibrocartilage Complex: distal to the radioulnar joint.
EXAMINING THE WRIST VOLAR PALPATION • Scaphoid tuberosity: Distal to the radial styloid, most prominent in radial deviation. • Trapezium: distally to the scaphoid, in the axis of the index finger. • Pisiform: bony prominence in the base of the hypothenal eminence • Hook of hamate: radially and distally to the pisiform. • Palmaris longus: present in 85%. Flexion of the wrist while opposing the thumb and little finger.
TENDON EXAMINATION - PASSIVE MOTION • In non - cooperative patient, sedated or in children. • Firm pression in the ulnar - anterior aspect of middle - distal third of forearm. • Intact tendons: 1 - 2 cm flexion especially in the ulnar 3 fingers. • For the FPL: Pressure on the distal - anterior radius: flexion of the IPJ of the thumb.
NERVE EXAMINATION SENSORY DISTRIBUTION • Sensory skin territories have ill defined boundaries and adjacent territories overlap extensively. • Sheddon’s classification of nerve injury: - Neuroapraxia: selective demyelinization of large fibres in the nerve with no axonal degeneration. - Axonotmesis: The axons are severed but the anatomical continuity of the nerve is preserved: the Schwann cells which form the sheath are uninterrupted. - Neurotmesis: Loss of continuity of the nerve. • Sudderland’s classification of nerve injury: I: Neuroapraxia. II: Axon severed - endoneurial tube intact. III: Endoneurial tube torn. IV: Only epineurium intact. V: Loss of continuity. VI: Combination of above.
NERVE EXAMINATION AUTONOMOUS ZONE In total recent nerve division the area of absolute sensory loss: • Ulnar nerve: palmar aspect of small finger. • Median nerve: palmar aspect of index finger. • Radial nerve: dorsum of MPJ of the thumb. • C5 Root: over the belly of the deltoid. • C6 Root: the thenar eminence. • C7 Root: NIL. • C8 Root: ulnar border of the hand. • T1 Root: ulnar border of the elbow. • T2 Root: inner aspect of the arm.
NERVE EXAMINATION TWO POINT DISCRIMINATION • Determines the minimal distance at which a patient can discriminate between being touched with one or two points. • Patient’s vision is blocked. • Distance of 5mm between points. • One or two points toutched in the center of the finger tip. • The instrument should be applied lightly. • Ten separate stimuli are given. If correct answers <7, distance increased. • Interpretation: Normal: <6 mm, Fair: 6 - 10 mm Poor: 11 - 15 mm, Protective: one point perceived, Anesthetic: no point perceived.
NERVE EXAMINATION TINEL’S TEST • Percutanous percussion of the nerve trunk with the tip of the finger. • Often positive in the site of nerve compression (carpal tunnel, cubital tunnel), or a little proximal to it, producing paraesthesia, radiating into the sensory distribution of the nerve. • The first detectable clinical sign of recovery - neural regeneration. • The «pins and needles» sensation is caused be regeneration of the sensory axons which are very sensitive to pressure. • It is absent in the early stages - appears 4 -6 weeks after the injury. May be difficult to elicit if the nerve lies deep to a large mass of muscle. • Should be interpreted only in conjunction with other clinical findings.
RECOVERY AFTER NERVE INJURY • Scale for the sensibility assessment (BMRC, Sheddon 1975): S0: Absence of sensibility in the autonomous area. S1: Recovery of deep cutaneous pain sensibility. S2: Return of some degree of superficial cutaneous pain and tacttile sensibility. S3: Return of superficial cutaneous pain and tactile sensibility with dissappearance of over - response. S3+: As in stage 3 with some recovery of the 2PD. S4: Complete recovery.
NERVE EXAMINATION TACTILE ADHERENCE TEST • Sweating is lost in the distribution of a divided peripheral nerve. • The digit in the denervated area is smooth and dry. • The smooth surface of a pen is passed gently but firmly back and forward in each side of the finger. • In the presence of sweat, adhesion is shown by a slight moving of the finger. • An insensate pulp with no sweating will show no motion
NERVE EXAMINATION PARALYSIS • Ulnar Nerve: FLEXOR DIGITI QUINTI • Median Nerve: ABDUCTOR POLLICIS BREVIS • Radial nerve: WRIST EXTENSORS • The inability to initiate movement is not an absolute evidence that the muscle or the nerve is damaged. Pain or even nervousness can inhibit motion. • The best way to examine a muscle is to place the limb in the position which the muscle normally produces, and instuct: “ Keep it there, don’t let me move it”.
NERVE EXAMINATION MUSCLE WAISTING • Paralysed muscles become increasingly atrophic. Most noticeable: - Abductor Pollicis Brevis: Median Nerve. - Abductor Digiti Quinti and 1st Dorsal Interosseous: Ulnar Nerve. • The deformity has two components: - Depression due to loss of muscle bulk, - Prominence of bones usually masked by muscle.
REFLEXES TESTING • Absent: Lower motor neuron disorders (division of motor nerve). • Exaggerated: Upper motor neuron injury (CVA and cord transection) • Biceps tendon: C5 nerve. • Brachioradialis: C6 nerve • Triceps tendon: C7 nerve.
VASCULAR EVALUATION In case of injury • Diminution or absence of distance Pulses. • Pallor - especially in the nailbeds. • Pain - most evident when handling the limb. • Paraesthesia - hypaesthesia - anaesthesia. • Paralysis - established compartment syndrome. • Cold - any temperature below 30°. In chronic cases: • Intermittent claudication. • Persistent ulceration. • Cold intolerance. • Colour change. • Stiffness of the joints.
VASCULAR EVALUATION • Assessment of color - temperature (in comparison to the unaffected fingers) - capillary refil. • Squeeze the fingrtip: after blanching refil> 2 sec or incomplete: arterial insufficiency suspected. • Extremely brisk capillary refil with dark blue coloration: venous insufficiency. • Futher assessment with fingertip puncture with steril 20 - gauze needle (in the anesthetised patient: bright red blood: no isufficiency, slowly flowing dark venous blood: arterial insufficiency, copious amounts of dark blood: venous insufficiency.
VASCULAR EVALUATION ALLEN’S TEST • Determines the patency of both the radial and the ulnar arteries. • The hand exsanguinated by digital pressure of both arteries and the patient making strong fist. • Pressure is released from the radial artery - patent return of color and capillary refil to the entire hand indicates patent radial artery and palmar arch. • Repeat step A and release the ulnar artery. • Normal filling time: <5 sec. • Similar test with the digital arteries of the finger: The digital Allen’s test.
VASCULAR EVALUATION RAYNAUD’S DISEASE • Small vessel spasm of unknown cause. • Cyclical colour and temperature changes in the digits. • Sudden onset of symmetrical - bilateral extreme pallor followed by cold pale cyanosis. • Raynaud’s phenomemon involves the same symptoms, with known underlying disorder (scleroderma, polyarteritis nodosa, SLE, RA, thrombangiitis obliterans etc.)
SPECIAL TESTS AND CONDITIONS
FINKELSTEIN TEST • Diagnostic in Stenosing tenosynovitis at the radial styloid (De Quervain’s Disease). • First dorsal compartment: Abductor Pollicis Longus, Extensor Pollicis Brevis. The synovium of the first compartment is particular prone to become inflamed. • The patient grasps the thumb firmly in the palm of his hand. • The examiner deviates abruptly the hand in ulnar deviation, placing maximum strength to the tendons, and producind severe pain. • Finkelsein manoeuvre is not comfortable even in the healthy hand - comparison. • May be positive in arthritis (precise localization of tenderness). • Radial sensory nerve neuritis (Wartenberg’s syndrome) may also produce falsely positive test - the same pain with the thumb excluded, during ulnar deviation.
WATSON’S TEST (SCAPHOID SHIFT TEST) • Scaphoid instability. • The thumb of one hand in the palmar aspect of the scaphoid and the index finger on the radial tubercle dorsally (wrist in ulnar deviation). • Maintaining firm pressure push the hand strongly in radial deviation. • If the ligaments of the proximal part of the scaphoid are lax or torn, the proximal pole will jump over the dorsal lip of the radius with a «clunk».
LICHTMAN TEST • Ulnar midcarpal instability . • The wrist pronated and palmar flexed. • Radially deviation of the wrist: observe the prominence of the triquetrum bone, 2cm distal to the ulnar head. • With ulnar deviation of the wrist it should disappear. • If it initially becomes more prominent and then vanishes with a palpable «clunk», ulnar midcarpal instability is present.
GRIND TEST OF THE TRAPEZIOMETACARPAL JOINT • Stabilize the hand - place the middle finger on the TMJ. • Grasp the thumb and push it towards the trapezium rotating it several times. • A gritting or grinding sensation of bone on bone felt by both the patient and doctor an pain: positive sign: TMJ arthritis.
RADIOCARPAL AP DRAWER TEST BALLOTMENT’S TEST • Demonstrate abnormal movements between adjacent bones by exerting pressure in opposite directions. • Radiocarpal drawer: Anteroposterior force is applied and a drawer is elicited in the radiocarpal joint. • LT Ballotment’s test: Instability of the lunotriquetral joint • Volar pressure on lunate and dorsal on the triquetrum. If there is any ligament damage, painful shearing of the joint will be produced.
CARPAL TUNNEL SYNDROME PHALEN’S TEST • Placing the wrists in maximum flexion, both hands in one time with the elbow extended (the normal hand acts as a control). • Onset of numbness - tingling in the median nerve distribution in less than 60 seconds is considered diagnostic for carpal syndrome. • Reversed Phalen’s test: Placing the palms of the hands together, raising the elbow as high as possible. Ocassionaly positive when the Phalen’s test is negative.
CARPAL TUNNEL SYNDROME CARPAL COMPRESSION - TINEL’S TEST • Pressure over the median nerve, immediately above the carpal tunnel produces parestaesias - tingling in the distribution of the medial nerve in carpal tunnel syndrome. • Very helpful in patients whose wrists cannot be flexed (rheumatoid or posttraumatic wrist arthritis). • Percussion over the carpal tunnel produces paresthesia in the distribution of the median nerve: TINEL’S test.
CARPAL TUNNEL SYNDROME APB MUSCLE STRENGTH TEST • Hand on the table - palm up and the patient brings the thumb up to 90° to the palm. • If muscle stengh impaired in CTS, consider additional procedure (Camitz procedure...). • D/D from pronator syndrome (compression of the median nerve between the 2 heads of PT): No nocturnal complaints - Dysaesthesia in the palmar triangle (palmar cutaneous branch of median nerve).
CUBITAL TUNNEL SYNDROME • Compression of the ulnar nerve in the cubital tunnel. • Paraesthesia - numbness in ring - small fingers, hypothenar eminence and ulnar half of the dorsum of the hand (d/d from compression in the Guyon’s canal). • Tinel’s sign positive over the ulnar nerve in the cubital tunnel. • Elbow flexion test: reproduces pain and paraesthesia (similar to Phalens test). • Weakness in the ulnar innervated muscles in the hand - waisting of the first web space.
RADIAL TUNNEL SYNDROME POSTERIOR INTEROSSEOUS NERVE SYNDROME • Compression of radial nerve in: - radiohumeral joint. - ECRB muscle. - Radial reccurent fan vessels. - Arcade of Froshe (supinator muscle). • No sensory symptoms or motor loss in RTS. • Tenderness over the extensor tendons distally to the elbow - resembling lateral epicondylitis (tennis elbow). • MIDDLE FINGER TEST: Resisted finger extension elicits greater pain in the extension of the middle finger (ECRB muscle inserts in the base of 3rd metacarpal). • PINS: Pain - weakness - paralysis of the muscles supplied by the posterior interosseous nerve.
THORACIC OUTLET SYNDROME (TOS) • Variations and combinations of neurologic and vascular symptoms affecting the upper limb. • Abnormal compression and irritation of the brachial plexus and suclavian artery. • Conditions congenital or aquired, can appear in one or several levels most probable in the thoracic outlet. • Below: first rib. Anteriorly: scalenous anterior. Behind: scalenous medius. • Cervical rib, rudimentary first rib (usually innocent), fibromuscular, tendinous or ligamentous bands, swelling, trauma, postular changes (the military brace position).
THREE - MINUTE ELEVATED ARM EXERCISE TEST, IN THE «SURRENDER» POSITION ROOS TEST • The most reliable in the diagnosis of thoracic outlet syndrome. • Arms abducted, elbow flexed. • Opens and closes his hands, keeping shoulders backwards. • Normal extremity: mild fatique. • Neurologic TOS: Early tingling in the fingers - hands - forarm, arm heavy, aches. • Venous TOS: Arm cyanotic from proximally to distally, and wrist veins become distended. • Arterial type: The pulse may be occluded, arm and hand become ischaemic, white, the muscles fail, the arm drops
LATERAL EPICONDYLITIS (TENNIS ELBOW) • Passive wrist flexion (pain in the common extensor origin). • Resisted wrist extension (pain in the common extensor origin). • Resisted extension of the middle finger (D/D from radial tunnel syndrome - pain proximal to the common extensor origin).
DUPUYTREN’S DISEASE • Contracture of the palmar fascia. • Familiar disorder - common in diabetics, smokers, patients using antiepileptic medication. • Commences with apainful palm nodule, progresses in the development of bands (affect (order of frequency): ring, small, middle, thumb, index fingers). • Grading (Woodruff, Waldram). - 1: Nodule - no contracture. - 2: MCP contracture only. - 3: MCP and PIP contracture. - 4: As with 3 with two fingers. - 5: Finger stuck in the palm. • Examine the dorsum of the PIPJ for Garrod’s knuckle pads.
PATHOGNOMONIC POSTURES • Cerebral palsy. • Brachial Plexus injuries. • Radial nerve . • Ulnar nerve . • Median nerve.
CEREBRAL PALSY • This differs from all other nerve lesions - apart from a cerebrovascular accident - in that it is an upper neuron injury, and there is a great degree of spasticity. • Extrinsic postural change: Flexion of elbow, wrist, fingers - pronation of forearm - adduction, flexion of thumb. • Intrinsic postural change: flexion of MCPJ, extension of IPJ: intrinsic - plus deformity.
UPPER ROOTS OF BRACHIAL PLEXUS ERB’S PALSY • Birth injuries - powerful blow to the shoulder with controlateral flexion of the cervical spine. • C5 - C6: loss of shoulder abduction - external rotation - elbow flexion - forearm supination: arm in the patient’s side internally rotated, extended at the elbow and pronated. • C7: Loss of elbow and wrist extension. The palm turns upwards to the rear at the level of the mid - thigh, the porter’s tip position.
LOWER ROOTS OF BRACHIAL PLEXUS KLUMPKE’S PARALYSIS • C8 - T1: Loss of all the intrinsic muscles of the hand - flatening and marked wasting. • Due to the weakness or absence of the long flexors there may be less dramatic change in posture.
RADIAL NERVE ABOVE THE ELBOW WRIST DROP • Loss of wrist and finger extensors, wrist drop posture. • The fingers may appear to extend remarkably well, but this is due to: 1) The tenodesis effect of wrist flexion in extending the MCPJ and 2) Active ulnar innervated intrinsics, extending the interphalangeal joints.
ULNAR NERVE AT THE WRIST CLAW HAND • Hyperextension of MCPJ and flexion of the IPJ of the ring and small fingers. • Paralysis of FDQ and lumpricals disturbs the balance of the MP joints, which are hyperextended by the long extensors. In the IP joints the long extensors lose and the long flexors gain mechanical advantage and adopt a flexed posture. • Ulnar clawing does not resulve when: 1) Martin - Gruber anastomosis: ulnar fibres travel with the median nerve to the forearm. 2) MCP joint cannot hyperextend due to arthritis - injury - stifness. 3) High ulnar nerve injuries above the FDP of the ring - small fingers: THE ULNAR PARADOX..
ULNAR NERVE AT THE WRIST CLAW HAND •THE BOUVIER MANOEUVER Important in assessing the claw hand. Hyperextension of the MCPJ is prevented and the patient asked to extend the finger: • Bouvierre positive: extension of the IPJ. • Bouvierre negative - passive positive: IPJ extends passively (extensor apparatus incopetent. • Bouvierre negative - passive nagative: IPJ fixed in flexion (skin shortening - flexor adhesions - palmar plate contractures).
ULNAR NERVE AT THE WRIST ULNAR ABDUCTED FINGER • If MCPJ cannot be hyperextended, the finger does not claw. • Loss of the third palmar interosseous muscle causes the small finger to abduct markedly into extension.
ULNAR NERVE AT THE WRIST FROMMENT’S SIGN • The patient is asked to pull a sheet of paper with index finger and thump, while the examiner withdraws it strongly. •The normal patient maintains maximum contact with the paper by extending the IPJ •In ulnar palsy FPL is too powerful for the combined IPJ extensors weakened by the loss of the contribution of the Adductor Pollicis. •Control of the MCPJ is lost, it collapses into hyperextension and IPJ flexes
MEDIAN NERVE BELOW THE ELBOW BENEDICTION SIGN • Anterior interosseous nerve palsy. • Arises from the median nerve 4-6 cm below the elbow. Entire motor nerve • Supply to FPL, FDP (Radial half), PQ. • Compression from tendinous band - accessory muscles, vascular pathology. • Symptoms: pain - weakness of pinch. • During pinch the distal phalanges of the thumb and index finger stay in extension. • Benediction sign: Inability to flex thumb - index finger (FDP to the middle finger many times gets innervation from the ulnar nerve).
COMBINED ULNAR AND MEDIAN NERVE SIMIAN HAND • Similar to the hand of an ape. • Full claw hand. • Thenar and hypothenar flattening due to muscle waisting. • Thumb adduction and flexion. • Also seen in Charcot -Marie - Tooth disease.
MALLET FINGER • DIPJ in flexion (10° - 40°). • Open or Close. • Traumatic or inflammatory origin. • Associated with avulsion fractures of the proximal portion of the distal phalanx. • Division or elongation of the terminal extensor tendon at the level of the DIPJ.
SWAN NECK DEFORMITY • Hyperextension of the PIPJ and flexion of the DIPJ. • Excessive traction by the extensor apparatus, inserted on the base of the middle phalanx: - Articular (lesion of structures which prevent hyperextension of the PIPJ). - Intrinsic muscle (interosseous contracture), palmar subluxation of the base of the proximal phalanx. - Increase of power of EC. • The deformity is reducible at first - gradually becomes fixed.
BOUTONNIERE DEFORMITY • Flexion of the PIPJ and hyperextension of the DIPJ. • After division, rupture or degeneration (rheumatoid arthritis) of the central tendon of the extensor aparratus in the dorsum of the PIPJ. • Lateral - palmar dislocation of the lateral extensor tendons which become flexors - the head of the proximal phalanx is “button holed”. • At an early stage the deformity is reducible: Haines - Zancolli test negative, if the middle phalanx is maintained in extension, flexion of the distal phalanx is still possible. • By time it becomes fixed: Haines - Zancolli test positive, flexion of the distal phalanx not possible.
PIANO KEY SIGN • Indicates ulnar head subluxation (rheumatoid patients). • The prominent ulnar head can be manually depressed by 5mm or more, usually with accompanying pain. • When pressure is released the head of the ulna springs back in its original position, like a key of the piano.
IMAGING EVALUATION STANDARD VIEWS • 4 views for the wrist: (PA, L, Oblique, PA with ulnar deviation). Central beam over the capitate head. • 3 views for the hand: (PA, L, Oblique). Central beam over the midportion of the 3rd metacarpal.
IMAGING EVALUATION SPECIAL VIEWS • Scaphoid views: Routine AP and then full ulnar deviation, with the central beam angled 20° towards the elbow. • Carpal tunnel views: the forearm flat on the cassete and maximum dorsiflex of the wrist. Axial view of the hamate, pisiform and volar margin of the trapezium. • Stress views: Soft tissue injuries (Gamekeeper’s Thumb)
IMAGING EVALUATION NORMAL ANGLES AND MEASUREMENTS • Three carpal arcs: Arc 1: proximal convexities of S, L, T. Arc 2: distal concavities os S, L, T. Arc 3: proximal convexities of C, H. • Radial inclination: 20° (16° - 28°). • Palmar tilt: 10° - 20°
IMAGING EVALUATION ARTHROGRAPHY • Ligamentous or cartilaginous abnormalities. • Major wrist compartments (don’t communicate): Radiocarpal cpt, Distal Radioulnar cpt, Midcarpal cpt. • Under fluoroscopic control - frequent spot filming. • 2:1 mixture of dilute water - soluble contrast to 1% lidocaine. • The joints are fully distended with contrast until the patient has mild discomfot. • The clinical significance of some arthrographic findings is difficult to access - all the abnormalities on arthrography must be carefully correlated with clinical examination.
IMAGING EVALUATION RADIONUCLIDE BONE IMAGING • Extremely sensitive but with low specificity. For evaluation of subtle wrist and hand injuries. • Technetium - 99m coupled to phosphate compounds. • Phase I: angiography, first 1 - 2 m provides blood flow information. • Phase II: blood pool images, 5 m after the injection, provides soft tissues information.. • Phase III: 2 - 3 h . Detects cartilage and bone information. • Acute phase after trauma (2 - 4 w): All three phases are positive. • Subacute stage (4 - 12 w):Phase I becomes normal. • Chronic stage (>12 w): Only stage III positive. • Diagnosis of RSD - AVN
IMAGING EVALUATION COMPUTED TOMOGRAPHY (CT) • Improved contrast resolution and planar representation of the carpal bones without the superimposition of anatomic structures. • Primary images in different planes. • Occult fractures of wrist bones - carpal fracture non - unions, bone graft incorporation, osseous fusion.
IMAGING EVALUATION MAGNETIC RESONANCE IMAGING (MRI) • Simultaneous and direct vision of bone cartilage and soft tissue. • Carpal ligamentous disruptions, DRUJ instability, TFCC disruptions, occult fractures, tendon ruptures, RSD, AVN. • T1 - weighted SE sequences and 3D -GRE sequenses performed.
IMAGING EVALUATION ULTRASONOGRAPHY • Examining structures in “real time”, during active motion. • Provides details of soft tissues. • Function and anatomic characteristics of tendons, ligaments, cartilage, soft tissue masses. • Highly machine and operator dependent technique.
WRIST ARTHROSCOPY • Indications: Evaluation of ligamentous injuries, examination of joint articular surfaces, removal of loose bodies, synovium biopsy, irrigation and joint debridement, confirmation and supplementary to wrist arthrography. • The usual arthroscopic portals are located between the extensor compartments of the wrist. • Arthroscopy is general more accurate in identifying the location and size of TFCC and interosseous ligament injuries.
ELECTRODIAGNOSIS ELECTROMYOGRAPHY - NERVE CONDUCTION • Electromyography: Stimulus applied directly to the muscle - the different response to different strengths of stimulus is indication of the condition of the muscle. • Nerve conduction: Apply stimulating electrodes over the course of the motor nerve proximally na drecording the muscle activity. The time between the stimulus and the action potential is the distal latency. • After 3w denervation can be confirmed on EMG. • Division or compression neuropathies can be detected and localized. • Re - innervation can be detected prior to clinical evidence of motor return.
REFERENCES • Campbell’s Operative Orthopaedics. • Examination of the hand and wrist. R. Tubiana, J Thomine, E. Mackin. • Journal of Hand Surgery. • Manual of acute hand injuries. D.S. Martin, E.D. Collins. • The hand: Diagnosis and indications. G. Lister.
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Tips on upper limb assessment

  • 1.
    Tips on upperlimb assessment Mr V Rajaratnam FRCS(Ed),Dip Hand Surgery (Eur) Consultant Hand Surgeon
  • 2.
    EXAMINING THE HAND •Systems of examination. • History. • Normal - abnormal positions and movements of the hand. • Special conditions and tests. • Radiological Evaluation. • Arthroscopy - Electrodiagnosis.
  • 3.
    HISTORY IMPORTANT QUESTIONS INALL CASES: •Social history (very important especially when considering operation) - professional - recreational activities. • Dominant hand. • Function of the whole upper limb - functional state of the opposite limb. • General health, known pathologies, current therapy (diabetes, rheumatoid arthritis, corticosteroid intake...) • psychological state, known allergies. • Smoking - alchohol intake. • Family history.
  • 4.
    HISTORY PERSONALITY - INTELLIGENCEAND RELIABILITY • Meeting the surgeon’s gaze. • Honesty of the patient. • Innapropriate affect: ill defined pain. • Malingering: Glove hypaesthesia, rapid echange grip strength, distracted function. •Liability: the patient wishes to extract maximum compensation. • After taking full history most of the surgeons have concluded to d/d of only a few pathological conditions.
  • 5.
    NORMAL POSITIONS OFTHE HAND •All fingers when flexed at the MCPJ and the PIPJ point to the tubercle of the scaphoid. •Very important in assessing the normal rotation in fractures of the metacarpals and phalanges. •In rotation malalignement the «scissoring» deformity is unacceptable, both cosmetically and functionally. •Observing the plane of the fingernails helps detecting any malrotation in case of fracture - always compare with the other limb.
  • 6.
    BASIC POSITIONS OFTHE HAND • Precision pinch: The tips of fingernails of index finger and thumb are brought together. • Pulp pinch: The pulps of index finger and thumb are opposed. Normal power 5 - 10 pounds. •Key pinch: The pulp of the thumb is opposed to the radial side of the middle phalanx of the index finger. Normal power 13 - 20 pounds. •Chuck grip: The digital pulps of index and middle fingers brought into contact with the pulp of the thumb.
  • 7.
    BASIC POSITIONS OFTHE HAND • Hook grip: The fingers are flexed in the IPJ and extended in the MCPJ. •Span grasp: From the hook grip the IPJ are extended 30° and the thumb abducted fully. •Power grasp: The fingers flexed fully and the opposed thumb is flexed over the fingers to increase power. Normal 90 - 100 pounds. The normal variation is 10%, but sometimes the dominant hand is not always stronger. •Flat hand: Fingers, thumb extended, thumb adducted.
  • 8.
    MUSCLE STRENGTH TESTING •The Jamar grip stength dynamometer. The combined efforts of the intrinsic and the extrinsic muscles are evaluated in Levels 1, 2 and 3. In Levels 4, 5 primary extrinsic muscle is evaluated. •The pinch meter. The pinch meter should be held lightly by the examiner and never fixed in any way during testing. • SCALE OF POWER: 0: Total paralysis - no contraction detectable on palpation. 1: Flicker - no movement, but contraction palpable. 2: Movement with gravity eliminated - placing the line of action of the muscle in the horizontal plane. 3: Movement against gravity. 4: Movement against gravity and resistance. 5: Full power.
  • 9.
    EXAMINING THE HAND RANGEOF MOTION • Perform full ROM active and passive in all the fingers in both hands. • Normal: MCPJ: 0 - 90° PIPJ: 0 - 120° DIPJ: 0 - 60° Thumb IPJ: 0 - 60°. • It is not possible to flex the DIPJ of 3 - 4 - 5 fingers independently. It is very important when the fingers flex , their pulp to touch the palm.
  • 10.
    EXAMINING THE HANDRANGE OF MOTION - THE THUMB • The 1st MCPJ (trapeziometacarpal) is functionally the most important because it allows movement of the whole column of the thumb. • There is confusion in terminology - different authors use different terms to describe thumb movements. • ABDUCTION: Seperation in the plane of the palm. • ANTEPOSITION: Seperation in a perpendicular plane to the plane of the palm. • ADDUCTION: Brings the thumb in contact with the palm • OPPOSITION: Complex movement: Anteposition and adduction of the 1st metacarpal, flexion of the MCPJ and IPJ, pronation of all the skeletal elements..
  • 11.
    EXAMINING THE WRIST RANGEOF MOTION • Perform full ROM active and passive in both hands. • Normal: Extension: 60° Flexion: 70° Wrist radial deviation: 20° Wrist ulnar deviation: 30° Forearm supination: 80° Forearm pronation: 80°
  • 12.
    EXAMINING THE WRIST DORSALPALPATION • Scaphoid: just distal to the radial styloid. Its tuberosity prominent in extension - radial deviation. The waist palpable deep to the anatomic snuffbox (always examine both hands). • Trapezium: distal to the scaphoid, along the axis of the thumb. Can be distinguished from the 1st metacarpal by gently rotating the thumb. • Lunate: Prominent with the wrist flexed, ulnar to the Lister’s tubercle. • Capitate: distal to the lunate. • Hamate: proximal to the 5th metacarpal. • Distal radioulnar joint: radial to the ulnar head. • Triangular Fibrocartilage Complex: distal to the radioulnar joint.
  • 13.
    EXAMINING THE WRIST VOLARPALPATION • Scaphoid tuberosity: Distal to the radial styloid, most prominent in radial deviation. • Trapezium: distally to the scaphoid, in the axis of the index finger. • Pisiform: bony prominence in the base of the hypothenal eminence • Hook of hamate: radially and distally to the pisiform. • Palmaris longus: present in 85%. Flexion of the wrist while opposing the thumb and little finger.
  • 14.
    TENDON EXAMINATION -PASSIVE MOTION • In non - cooperative patient, sedated or in children. • Firm pression in the ulnar - anterior aspect of middle - distal third of forearm. • Intact tendons: 1 - 2 cm flexion especially in the ulnar 3 fingers. • For the FPL: Pressure on the distal - anterior radius: flexion of the IPJ of the thumb.
  • 15.
    NERVE EXAMINATION SENSORY DISTRIBUTION •Sensory skin territories have ill defined boundaries and adjacent territories overlap extensively. • Sheddon’s classification of nerve injury: - Neuroapraxia: selective demyelinization of large fibres in the nerve with no axonal degeneration. - Axonotmesis: The axons are severed but the anatomical continuity of the nerve is preserved: the Schwann cells which form the sheath are uninterrupted. - Neurotmesis: Loss of continuity of the nerve. • Sudderland’s classification of nerve injury: I: Neuroapraxia. II: Axon severed - endoneurial tube intact. III: Endoneurial tube torn. IV: Only epineurium intact. V: Loss of continuity. VI: Combination of above.
  • 16.
    NERVE EXAMINATION AUTONOMOUS ZONE Intotal recent nerve division the area of absolute sensory loss: • Ulnar nerve: palmar aspect of small finger. • Median nerve: palmar aspect of index finger. • Radial nerve: dorsum of MPJ of the thumb. • C5 Root: over the belly of the deltoid. • C6 Root: the thenar eminence. • C7 Root: NIL. • C8 Root: ulnar border of the hand. • T1 Root: ulnar border of the elbow. • T2 Root: inner aspect of the arm.
  • 17.
    NERVE EXAMINATION TWO POINTDISCRIMINATION • Determines the minimal distance at which a patient can discriminate between being touched with one or two points. • Patient’s vision is blocked. • Distance of 5mm between points. • One or two points toutched in the center of the finger tip. • The instrument should be applied lightly. • Ten separate stimuli are given. If correct answers <7, distance increased. • Interpretation: Normal: <6 mm, Fair: 6 - 10 mm Poor: 11 - 15 mm, Protective: one point perceived, Anesthetic: no point perceived.
  • 18.
    NERVE EXAMINATION TINEL’S TEST •Percutanous percussion of the nerve trunk with the tip of the finger. • Often positive in the site of nerve compression (carpal tunnel, cubital tunnel), or a little proximal to it, producing paraesthesia, radiating into the sensory distribution of the nerve. • The first detectable clinical sign of recovery - neural regeneration. • The «pins and needles» sensation is caused be regeneration of the sensory axons which are very sensitive to pressure. • It is absent in the early stages - appears 4 -6 weeks after the injury. May be difficult to elicit if the nerve lies deep to a large mass of muscle. • Should be interpreted only in conjunction with other clinical findings.
  • 19.
    RECOVERY AFTER NERVEINJURY • Scale for the sensibility assessment (BMRC, Sheddon 1975): S0: Absence of sensibility in the autonomous area. S1: Recovery of deep cutaneous pain sensibility. S2: Return of some degree of superficial cutaneous pain and tacttile sensibility. S3: Return of superficial cutaneous pain and tactile sensibility with dissappearance of over - response. S3+: As in stage 3 with some recovery of the 2PD. S4: Complete recovery.
  • 20.
    NERVE EXAMINATION TACTILE ADHERENCETEST • Sweating is lost in the distribution of a divided peripheral nerve. • The digit in the denervated area is smooth and dry. • The smooth surface of a pen is passed gently but firmly back and forward in each side of the finger. • In the presence of sweat, adhesion is shown by a slight moving of the finger. • An insensate pulp with no sweating will show no motion
  • 21.
    NERVE EXAMINATION PARALYSIS • UlnarNerve: FLEXOR DIGITI QUINTI • Median Nerve: ABDUCTOR POLLICIS BREVIS • Radial nerve: WRIST EXTENSORS • The inability to initiate movement is not an absolute evidence that the muscle or the nerve is damaged. Pain or even nervousness can inhibit motion. • The best way to examine a muscle is to place the limb in the position which the muscle normally produces, and instuct: “ Keep it there, don’t let me move it”.
  • 22.
    NERVE EXAMINATION MUSCLE WAISTING •Paralysed muscles become increasingly atrophic. Most noticeable: - Abductor Pollicis Brevis: Median Nerve. - Abductor Digiti Quinti and 1st Dorsal Interosseous: Ulnar Nerve. • The deformity has two components: - Depression due to loss of muscle bulk, - Prominence of bones usually masked by muscle.
  • 23.
    REFLEXES TESTING • Absent:Lower motor neuron disorders (division of motor nerve). • Exaggerated: Upper motor neuron injury (CVA and cord transection) • Biceps tendon: C5 nerve. • Brachioradialis: C6 nerve • Triceps tendon: C7 nerve.
  • 24.
    VASCULAR EVALUATION In caseof injury • Diminution or absence of distance Pulses. • Pallor - especially in the nailbeds. • Pain - most evident when handling the limb. • Paraesthesia - hypaesthesia - anaesthesia. • Paralysis - established compartment syndrome. • Cold - any temperature below 30°. In chronic cases: • Intermittent claudication. • Persistent ulceration. • Cold intolerance. • Colour change. • Stiffness of the joints.
  • 25.
    VASCULAR EVALUATION • Assessmentof color - temperature (in comparison to the unaffected fingers) - capillary refil. • Squeeze the fingrtip: after blanching refil> 2 sec or incomplete: arterial insufficiency suspected. • Extremely brisk capillary refil with dark blue coloration: venous insufficiency. • Futher assessment with fingertip puncture with steril 20 - gauze needle (in the anesthetised patient: bright red blood: no isufficiency, slowly flowing dark venous blood: arterial insufficiency, copious amounts of dark blood: venous insufficiency.
  • 26.
    VASCULAR EVALUATION ALLEN’S TEST •Determines the patency of both the radial and the ulnar arteries. • The hand exsanguinated by digital pressure of both arteries and the patient making strong fist. • Pressure is released from the radial artery - patent return of color and capillary refil to the entire hand indicates patent radial artery and palmar arch. • Repeat step A and release the ulnar artery. • Normal filling time: <5 sec. • Similar test with the digital arteries of the finger: The digital Allen’s test.
  • 27.
    VASCULAR EVALUATION RAYNAUD’S DISEASE •Small vessel spasm of unknown cause. • Cyclical colour and temperature changes in the digits. • Sudden onset of symmetrical - bilateral extreme pallor followed by cold pale cyanosis. • Raynaud’s phenomemon involves the same symptoms, with known underlying disorder (scleroderma, polyarteritis nodosa, SLE, RA, thrombangiitis obliterans etc.)
  • 28.
  • 29.
    FINKELSTEIN TEST • Diagnosticin Stenosing tenosynovitis at the radial styloid (De Quervain’s Disease). • First dorsal compartment: Abductor Pollicis Longus, Extensor Pollicis Brevis. The synovium of the first compartment is particular prone to become inflamed. • The patient grasps the thumb firmly in the palm of his hand. • The examiner deviates abruptly the hand in ulnar deviation, placing maximum strength to the tendons, and producind severe pain. • Finkelsein manoeuvre is not comfortable even in the healthy hand - comparison. • May be positive in arthritis (precise localization of tenderness). • Radial sensory nerve neuritis (Wartenberg’s syndrome) may also produce falsely positive test - the same pain with the thumb excluded, during ulnar deviation.
  • 30.
    WATSON’S TEST (SCAPHOID SHIFTTEST) • Scaphoid instability. • The thumb of one hand in the palmar aspect of the scaphoid and the index finger on the radial tubercle dorsally (wrist in ulnar deviation). • Maintaining firm pressure push the hand strongly in radial deviation. • If the ligaments of the proximal part of the scaphoid are lax or torn, the proximal pole will jump over the dorsal lip of the radius with a «clunk».
  • 31.
    LICHTMAN TEST • Ulnarmidcarpal instability . • The wrist pronated and palmar flexed. • Radially deviation of the wrist: observe the prominence of the triquetrum bone, 2cm distal to the ulnar head. • With ulnar deviation of the wrist it should disappear. • If it initially becomes more prominent and then vanishes with a palpable «clunk», ulnar midcarpal instability is present.
  • 32.
    GRIND TEST OFTHE TRAPEZIOMETACARPAL JOINT • Stabilize the hand - place the middle finger on the TMJ. • Grasp the thumb and push it towards the trapezium rotating it several times. • A gritting or grinding sensation of bone on bone felt by both the patient and doctor an pain: positive sign: TMJ arthritis.
  • 33.
    RADIOCARPAL AP DRAWERTEST BALLOTMENT’S TEST • Demonstrate abnormal movements between adjacent bones by exerting pressure in opposite directions. • Radiocarpal drawer: Anteroposterior force is applied and a drawer is elicited in the radiocarpal joint. • LT Ballotment’s test: Instability of the lunotriquetral joint • Volar pressure on lunate and dorsal on the triquetrum. If there is any ligament damage, painful shearing of the joint will be produced.
  • 34.
    CARPAL TUNNEL SYNDROME PHALEN’STEST • Placing the wrists in maximum flexion, both hands in one time with the elbow extended (the normal hand acts as a control). • Onset of numbness - tingling in the median nerve distribution in less than 60 seconds is considered diagnostic for carpal syndrome. • Reversed Phalen’s test: Placing the palms of the hands together, raising the elbow as high as possible. Ocassionaly positive when the Phalen’s test is negative.
  • 35.
    CARPAL TUNNEL SYNDROME CARPALCOMPRESSION - TINEL’S TEST • Pressure over the median nerve, immediately above the carpal tunnel produces parestaesias - tingling in the distribution of the medial nerve in carpal tunnel syndrome. • Very helpful in patients whose wrists cannot be flexed (rheumatoid or posttraumatic wrist arthritis). • Percussion over the carpal tunnel produces paresthesia in the distribution of the median nerve: TINEL’S test.
  • 36.
    CARPAL TUNNEL SYNDROME APBMUSCLE STRENGTH TEST • Hand on the table - palm up and the patient brings the thumb up to 90° to the palm. • If muscle stengh impaired in CTS, consider additional procedure (Camitz procedure...). • D/D from pronator syndrome (compression of the median nerve between the 2 heads of PT): No nocturnal complaints - Dysaesthesia in the palmar triangle (palmar cutaneous branch of median nerve).
  • 37.
    CUBITAL TUNNEL SYNDROME •Compression of the ulnar nerve in the cubital tunnel. • Paraesthesia - numbness in ring - small fingers, hypothenar eminence and ulnar half of the dorsum of the hand (d/d from compression in the Guyon’s canal). • Tinel’s sign positive over the ulnar nerve in the cubital tunnel. • Elbow flexion test: reproduces pain and paraesthesia (similar to Phalens test). • Weakness in the ulnar innervated muscles in the hand - waisting of the first web space.
  • 38.
    RADIAL TUNNEL SYNDROME POSTERIORINTEROSSEOUS NERVE SYNDROME • Compression of radial nerve in: - radiohumeral joint. - ECRB muscle. - Radial reccurent fan vessels. - Arcade of Froshe (supinator muscle). • No sensory symptoms or motor loss in RTS. • Tenderness over the extensor tendons distally to the elbow - resembling lateral epicondylitis (tennis elbow). • MIDDLE FINGER TEST: Resisted finger extension elicits greater pain in the extension of the middle finger (ECRB muscle inserts in the base of 3rd metacarpal). • PINS: Pain - weakness - paralysis of the muscles supplied by the posterior interosseous nerve.
  • 39.
    THORACIC OUTLET SYNDROME (TOS) •Variations and combinations of neurologic and vascular symptoms affecting the upper limb. • Abnormal compression and irritation of the brachial plexus and suclavian artery. • Conditions congenital or aquired, can appear in one or several levels most probable in the thoracic outlet. • Below: first rib. Anteriorly: scalenous anterior. Behind: scalenous medius. • Cervical rib, rudimentary first rib (usually innocent), fibromuscular, tendinous or ligamentous bands, swelling, trauma, postular changes (the military brace position).
  • 40.
    THREE - MINUTEELEVATED ARM EXERCISE TEST, IN THE «SURRENDER» POSITION ROOS TEST • The most reliable in the diagnosis of thoracic outlet syndrome. • Arms abducted, elbow flexed. • Opens and closes his hands, keeping shoulders backwards. • Normal extremity: mild fatique. • Neurologic TOS: Early tingling in the fingers - hands - forarm, arm heavy, aches. • Venous TOS: Arm cyanotic from proximally to distally, and wrist veins become distended. • Arterial type: The pulse may be occluded, arm and hand become ischaemic, white, the muscles fail, the arm drops
  • 41.
    LATERAL EPICONDYLITIS (TENNIS ELBOW) •Passive wrist flexion (pain in the common extensor origin). • Resisted wrist extension (pain in the common extensor origin). • Resisted extension of the middle finger (D/D from radial tunnel syndrome - pain proximal to the common extensor origin).
  • 42.
    DUPUYTREN’S DISEASE • Contractureof the palmar fascia. • Familiar disorder - common in diabetics, smokers, patients using antiepileptic medication. • Commences with apainful palm nodule, progresses in the development of bands (affect (order of frequency): ring, small, middle, thumb, index fingers). • Grading (Woodruff, Waldram). - 1: Nodule - no contracture. - 2: MCP contracture only. - 3: MCP and PIP contracture. - 4: As with 3 with two fingers. - 5: Finger stuck in the palm. • Examine the dorsum of the PIPJ for Garrod’s knuckle pads.
  • 43.
    PATHOGNOMONIC POSTURES • Cerebralpalsy. • Brachial Plexus injuries. • Radial nerve . • Ulnar nerve . • Median nerve.
  • 44.
    CEREBRAL PALSY • Thisdiffers from all other nerve lesions - apart from a cerebrovascular accident - in that it is an upper neuron injury, and there is a great degree of spasticity. • Extrinsic postural change: Flexion of elbow, wrist, fingers - pronation of forearm - adduction, flexion of thumb. • Intrinsic postural change: flexion of MCPJ, extension of IPJ: intrinsic - plus deformity.
  • 45.
    UPPER ROOTS OFBRACHIAL PLEXUS ERB’S PALSY • Birth injuries - powerful blow to the shoulder with controlateral flexion of the cervical spine. • C5 - C6: loss of shoulder abduction - external rotation - elbow flexion - forearm supination: arm in the patient’s side internally rotated, extended at the elbow and pronated. • C7: Loss of elbow and wrist extension. The palm turns upwards to the rear at the level of the mid - thigh, the porter’s tip position.
  • 46.
    LOWER ROOTS OFBRACHIAL PLEXUS KLUMPKE’S PARALYSIS • C8 - T1: Loss of all the intrinsic muscles of the hand - flatening and marked wasting. • Due to the weakness or absence of the long flexors there may be less dramatic change in posture.
  • 47.
    RADIAL NERVE ABOVETHE ELBOW WRIST DROP • Loss of wrist and finger extensors, wrist drop posture. • The fingers may appear to extend remarkably well, but this is due to: 1) The tenodesis effect of wrist flexion in extending the MCPJ and 2) Active ulnar innervated intrinsics, extending the interphalangeal joints.
  • 48.
    ULNAR NERVE ATTHE WRIST CLAW HAND • Hyperextension of MCPJ and flexion of the IPJ of the ring and small fingers. • Paralysis of FDQ and lumpricals disturbs the balance of the MP joints, which are hyperextended by the long extensors. In the IP joints the long extensors lose and the long flexors gain mechanical advantage and adopt a flexed posture. • Ulnar clawing does not resulve when: 1) Martin - Gruber anastomosis: ulnar fibres travel with the median nerve to the forearm. 2) MCP joint cannot hyperextend due to arthritis - injury - stifness. 3) High ulnar nerve injuries above the FDP of the ring - small fingers: THE ULNAR PARADOX..
  • 49.
    ULNAR NERVE ATTHE WRIST CLAW HAND •THE BOUVIER MANOEUVER Important in assessing the claw hand. Hyperextension of the MCPJ is prevented and the patient asked to extend the finger: • Bouvierre positive: extension of the IPJ. • Bouvierre negative - passive positive: IPJ extends passively (extensor apparatus incopetent. • Bouvierre negative - passive nagative: IPJ fixed in flexion (skin shortening - flexor adhesions - palmar plate contractures).
  • 50.
    ULNAR NERVE ATTHE WRIST ULNAR ABDUCTED FINGER • If MCPJ cannot be hyperextended, the finger does not claw. • Loss of the third palmar interosseous muscle causes the small finger to abduct markedly into extension.
  • 51.
    ULNAR NERVE ATTHE WRIST FROMMENT’S SIGN • The patient is asked to pull a sheet of paper with index finger and thump, while the examiner withdraws it strongly. •The normal patient maintains maximum contact with the paper by extending the IPJ •In ulnar palsy FPL is too powerful for the combined IPJ extensors weakened by the loss of the contribution of the Adductor Pollicis. •Control of the MCPJ is lost, it collapses into hyperextension and IPJ flexes
  • 52.
    MEDIAN NERVE BELOWTHE ELBOW BENEDICTION SIGN • Anterior interosseous nerve palsy. • Arises from the median nerve 4-6 cm below the elbow. Entire motor nerve • Supply to FPL, FDP (Radial half), PQ. • Compression from tendinous band - accessory muscles, vascular pathology. • Symptoms: pain - weakness of pinch. • During pinch the distal phalanges of the thumb and index finger stay in extension. • Benediction sign: Inability to flex thumb - index finger (FDP to the middle finger many times gets innervation from the ulnar nerve).
  • 53.
    COMBINED ULNAR ANDMEDIAN NERVE SIMIAN HAND • Similar to the hand of an ape. • Full claw hand. • Thenar and hypothenar flattening due to muscle waisting. • Thumb adduction and flexion. • Also seen in Charcot -Marie - Tooth disease.
  • 54.
    MALLET FINGER • DIPJin flexion (10° - 40°). • Open or Close. • Traumatic or inflammatory origin. • Associated with avulsion fractures of the proximal portion of the distal phalanx. • Division or elongation of the terminal extensor tendon at the level of the DIPJ.
  • 55.
    SWAN NECK DEFORMITY •Hyperextension of the PIPJ and flexion of the DIPJ. • Excessive traction by the extensor apparatus, inserted on the base of the middle phalanx: - Articular (lesion of structures which prevent hyperextension of the PIPJ). - Intrinsic muscle (interosseous contracture), palmar subluxation of the base of the proximal phalanx. - Increase of power of EC. • The deformity is reducible at first - gradually becomes fixed.
  • 56.
    BOUTONNIERE DEFORMITY • Flexionof the PIPJ and hyperextension of the DIPJ. • After division, rupture or degeneration (rheumatoid arthritis) of the central tendon of the extensor aparratus in the dorsum of the PIPJ. • Lateral - palmar dislocation of the lateral extensor tendons which become flexors - the head of the proximal phalanx is “button holed”. • At an early stage the deformity is reducible: Haines - Zancolli test negative, if the middle phalanx is maintained in extension, flexion of the distal phalanx is still possible. • By time it becomes fixed: Haines - Zancolli test positive, flexion of the distal phalanx not possible.
  • 57.
    PIANO KEY SIGN •Indicates ulnar head subluxation (rheumatoid patients). • The prominent ulnar head can be manually depressed by 5mm or more, usually with accompanying pain. • When pressure is released the head of the ulna springs back in its original position, like a key of the piano.
  • 58.
    IMAGING EVALUATION STANDARD VIEWS •4 views for the wrist: (PA, L, Oblique, PA with ulnar deviation). Central beam over the capitate head. • 3 views for the hand: (PA, L, Oblique). Central beam over the midportion of the 3rd metacarpal.
  • 59.
    IMAGING EVALUATION SPECIAL VIEWS •Scaphoid views: Routine AP and then full ulnar deviation, with the central beam angled 20° towards the elbow. • Carpal tunnel views: the forearm flat on the cassete and maximum dorsiflex of the wrist. Axial view of the hamate, pisiform and volar margin of the trapezium. • Stress views: Soft tissue injuries (Gamekeeper’s Thumb)
  • 60.
    IMAGING EVALUATION NORMAL ANGLESAND MEASUREMENTS • Three carpal arcs: Arc 1: proximal convexities of S, L, T. Arc 2: distal concavities os S, L, T. Arc 3: proximal convexities of C, H. • Radial inclination: 20° (16° - 28°). • Palmar tilt: 10° - 20°
  • 61.
    IMAGING EVALUATION ARTHROGRAPHY • Ligamentousor cartilaginous abnormalities. • Major wrist compartments (don’t communicate): Radiocarpal cpt, Distal Radioulnar cpt, Midcarpal cpt. • Under fluoroscopic control - frequent spot filming. • 2:1 mixture of dilute water - soluble contrast to 1% lidocaine. • The joints are fully distended with contrast until the patient has mild discomfot. • The clinical significance of some arthrographic findings is difficult to access - all the abnormalities on arthrography must be carefully correlated with clinical examination.
  • 62.
    IMAGING EVALUATION RADIONUCLIDE BONEIMAGING • Extremely sensitive but with low specificity. For evaluation of subtle wrist and hand injuries. • Technetium - 99m coupled to phosphate compounds. • Phase I: angiography, first 1 - 2 m provides blood flow information. • Phase II: blood pool images, 5 m after the injection, provides soft tissues information.. • Phase III: 2 - 3 h . Detects cartilage and bone information. • Acute phase after trauma (2 - 4 w): All three phases are positive. • Subacute stage (4 - 12 w):Phase I becomes normal. • Chronic stage (>12 w): Only stage III positive. • Diagnosis of RSD - AVN
  • 63.
    IMAGING EVALUATION COMPUTED TOMOGRAPHY(CT) • Improved contrast resolution and planar representation of the carpal bones without the superimposition of anatomic structures. • Primary images in different planes. • Occult fractures of wrist bones - carpal fracture non - unions, bone graft incorporation, osseous fusion.
  • 64.
    IMAGING EVALUATION MAGNETIC RESONANCEIMAGING (MRI) • Simultaneous and direct vision of bone cartilage and soft tissue. • Carpal ligamentous disruptions, DRUJ instability, TFCC disruptions, occult fractures, tendon ruptures, RSD, AVN. • T1 - weighted SE sequences and 3D -GRE sequenses performed.
  • 65.
    IMAGING EVALUATION ULTRASONOGRAPHY • Examiningstructures in “real time”, during active motion. • Provides details of soft tissues. • Function and anatomic characteristics of tendons, ligaments, cartilage, soft tissue masses. • Highly machine and operator dependent technique.
  • 66.
    WRIST ARTHROSCOPY • Indications:Evaluation of ligamentous injuries, examination of joint articular surfaces, removal of loose bodies, synovium biopsy, irrigation and joint debridement, confirmation and supplementary to wrist arthrography. • The usual arthroscopic portals are located between the extensor compartments of the wrist. • Arthroscopy is general more accurate in identifying the location and size of TFCC and interosseous ligament injuries.
  • 67.
    ELECTRODIAGNOSIS ELECTROMYOGRAPHY - NERVECONDUCTION • Electromyography: Stimulus applied directly to the muscle - the different response to different strengths of stimulus is indication of the condition of the muscle. • Nerve conduction: Apply stimulating electrodes over the course of the motor nerve proximally na drecording the muscle activity. The time between the stimulus and the action potential is the distal latency. • After 3w denervation can be confirmed on EMG. • Division or compression neuropathies can be detected and localized. • Re - innervation can be detected prior to clinical evidence of motor return.
  • 68.
    REFERENCES • Campbell’s OperativeOrthopaedics. • Examination of the hand and wrist. R. Tubiana, J Thomine, E. Mackin. • Journal of Hand Surgery. • Manual of acute hand injuries. D.S. Martin, E.D. Collins. • The hand: Diagnosis and indications. G. Lister.
  • 69.