Wrist & Hand Examination

History

• Falls

  • Onto outstretched hand Blunt force trauma

  • Finger valgus/varus

  • Thumb Abduction

  • Compression through medial column

  • Wrist extension & radial deviation

• Lacerations

  • Flexor tendons

• Repetitive activities

  • Especially anything involving repetitive finger flexion in wrist extension (e.g., typing)

Red Flags

• Diffuse upper extremity pain, especially left upper extremity

  • In the absence of neuromusculoskeletal findings

  • In the presence of shortness of beath, fatigue, general malaise

• Bilateral paresthesia with/or without loss of dexterity

Yellow Flags

• Irrational fear of movement

• Catastrophizing

• Symptom Magnification

• Feeling down, depressed, or hopelessness

• Loss of interest or pleasure in usual activities

Systems Review

• Cardiopulmonary

  • All patients at initial exam (Blood Pressure & Heart Rate)

  • As relevant to setting or patient (Respiratory Rate & O2 Saturation)

• Neurological

  • All patients at initial exam (Cognition & Communication)

  • As relevant to setting or patient (Coordination & Balance)

• Integumentary

  • All patients throughout episode of care (color, integrity, growths/spots)

• Musculoskeletal

  • All patients at initial exam (Height, weight, BMI)

  • As relevant to setting or patient (Upper & Lower Quarter Screen)

  • LQ – forward bend, full squat, single leg stand, walk on heels and toes

  • UQ – Turn head side-to-side, arms overhead, arms behind back, resisted shoulder abduction, squeeze therapist’s fingers

Systems Review - Cardiopulmonary

All patients at initial exam (Blood Pressure & Heart Rate)

As relevant to setting or patient (Respiratory Rate & O2 Saturation)

Systems Review - Neurological

All patients at initial exam (Cognition & Communication)

As relevant to setting or patient (Coordination & Balance)

Systems Review - Integumentary

All patients throughout episode of care (color, integrity, growths/spots)

Systems Review - Musculoskeletal

• All patients at initial exam (Height, weight, BMI)

• As relevant to setting or patient (Upper & Lower Quarter Screen)

• LQ – forward bend, full squat, single leg stand, walk on heels and toes

• UQ – Turn head side-to-side, arms overhead, arms behind back, resisted shoulder abduction, squeeze therapist’s fingers

Dermatome - C2

dorsal lateral scalp

Dermatome - C3

behind ear

Dermatome - C4

lateral neck

Dermatome - C5

anterior-lateral shoulder

Dermatome - C6

dorsal thumb

Dermatome - c7

dorsal aspect of the proximal phalanx of the middle finger

Dermatome - c8

medial aspect of the hand (hypothenar eminance)

Dermatome - T1

medial proximal forearm

myotome - C1

craniocervical flexion

myotome - C2

craniocervical extension

myotome - c3

cervical lateral flexion

myotome - c4

scapular elevation

myotome - c5

shoulder abduction

myotome - c6

elbow flexion or wrist extension

myotome - c7

elbow extension or wrist flexion

myotome - c8

thumb adduction or extension

myotome - t1

finger abduction

deep tendon reflex - c5

bicep

deep tendon reflex - c6

brachioradialis

deep tendon reflex - c7

triceps

observations

global

• postural alignment

• structure and symmetry

regional

• edema

• muscle bulk

• sympathetic changes

local (wrist and hand)

• hand position (nerve injury)

• finger deformities (structural injury)

• nail pathologies (health issues)

ape hand

median nerve

claw hand

median and ulnar nerve

bishops hand

ulnar nerve

local observations

trigger finger, mallet finger, boutonniere deformity, swan neck deformity

Beau’s Lines

• Transverse lines or ridges marking repeated disturbances of nail growth

• Systemic disease, toxic or nutritional deficiency states, trauma to nails

Defluvium Unguium (Onychomadesis)

Complete loss of nail

Certain systemic diseases such as scarlet fever, syphilis, leprosy, alopecia areata, and exfoliative dermatitis

Eggshell Nails

Nail plate thin, semitransparent bluish-white, with a tendency to curve upward at the distal edge

syphilis

Fragilitas Unguium

Friable or brittle nails

Dietary deficiency, local trauma

Hapalonychia

Nails very soft, easily split

Contact with strong alkalis, endocrine disturbances, malnutrition, syphilis, chronic arthritis

Koilonychia

“Spoon nails”; nails are concave on the outer surface

Acromegaly, trauma, dermatoses, syphilis, nutritional deficiencies, hypothyroidism

Leukonychia

White spots or striations

Local trauma, hepatic cirrhosis, nutritional deficiencies, many systemic diseases

Resisted Testing

• Resisted test (Gross force generating capacity)

  • Ensure patient is in a stable position

  • Large surface contact with hands

  • Ramp up (2-3 seconds each)

  • Sustained hold at maximum force (3-5 seconds)

  • Ramp down (2-3 seconds)

  • Break test (not a make test)

  • Return patient’s body part back to them when finished!

• Findings/Scoring

  • Quality contraction vs. Poor contraction

  • Strong vs. Weak

  • Painful vs. Non-painful

Manual Muscle Testing

• Used when gross weakness is identified and need to increase specificity of which muscles are affected

• Used when history indicates potential for isolated muscle weakness (e.g., peripheral nerve injury)

• Same as resisted test just in defined positions and targeting specific muscles

• Scoring

  • Against gravity (grades 3-5)

  • Gravity eliminated (grades 0-2)

Joint Mobility Testing

• “How much unrestricted joint glide is available in a particular direction?”

• Amount of pressure is VERY gentle

• Performed in the resting position for the joint

radio-carpal jt - concave/convex

Convex carpals on concave radius

Thumb CMC Jt. - concave/convex

(Flexion-Extension) – Concave metacarpal on convex trapezium

(Abd-Add) – Convex metacarpal on concave trapezium

Finger MCP & IP Jts. - concave/convex

Concave distal component on convex proximal component

Radiocarpal - resting

slight palmar flexion, ulnar deviation

radiocarpal - closed packed

max extension

thumb CMC - resting

midway between flexion-extension and abduction-adduction

thumb CMC - closed packed

maximal opposition

metacarpal phalangeal (I) - resting

slight flexion

metacarpal phalangeal (I) - close packed

maximal extension

metacarpal phalangeal (II - V) - resting

slight flexion and ulnar flexion

metacarpal phalangeal (II - V)- closed packed

maximal flexion

interphalangeal - resting

slight flexion

interphalangeal - close packed

maximal extension

special tests

• Used to increase or decrease confidence in the presence of a specific condition

• Pretest probability determined by history and physical exam

• Post-test probability based on the psychometric properties of the test (e.g. LR)

Special test - Detecting Carpal Tunnel Syndrome

• Wainner et al. Cluster (if all 5 present +LR = 18.3)

  • Brigham and Women’s Hospital Hand Severity Scale Score of > 1.9

  • Wrist ratio index greater than .67

  • Patient reports shaking the hand for symptom relief

  • Diminished sensation on the thumb pad

  • Age > 45

• Phalen and Reverse Phalen Test (+LR = 0.6 – 7.1; -LR = 0.9 – 1.66)

• Upper Limb Tension Test A & B (+LR = 0.75 – 3.67; -LR = 0.5 – 1.9)

wrist ratio

palmar to dorsal/ radial to ulnar

performance based tests

grip strength, pinch strength

Outcome Measures

• upper extremity function index

• Disabilities of the Arm, Shoulder, and Hand (DASH)

• Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH)

• Michigan Hand Outcomes Questionnaire