Forearm, Wrist, and Hand Evaluation

survey the scene (7)

• determine the severity (deformity, loss of function)

• check circulation (radial and ulnar artery, nail beds)

• check neurological involvement (radial, median, and ulnar nerves)

• quick history

• immobilize

• transport

• if chronic, develop a good history

history (12)

• Normal history (8)

  • onset (acute vs chronic)

  • MOI (fall/land on hand, position at time of impact, direct/indirect blow, amount of force, and angle of impact

  • unusual sounds or sensations

  • location of pn

  • type of pn

  • what activities aggravate the condition

  • signs and symptoms improving, getting worse, staying the same

  • previous hx

• Questions associated with previous injury (4)

  • signs and symptoms similar to prior injury/condition

  • did signs and symptoms completely subside

  • extent of treatment/rehab with previous injury

  • was full function restored?

observation (8)

• willingness and ability to use hand

• contours of forearm, hand, and wrist (muscle wasting in palm, peaks/valleys of MCP joints, make a fist (does it look normal?))

• position of hand (is the hand in the position of function?)

  • wrist: extension

  • fingers: flexed, parallel to each other

  • thumb: parallel to forearm

  • hand hanign limp or other obvious deformity

• swelling

• discoloration

• abrasions, lacerations, bleeding

• scars

• nailbed appearance

  • pink = normal

  • white = anemia/circulatory issues

  • blue = cyanotic

  • subungal hematoma

  • spoon nails - fungus infection

  • clubbed nails - respiratory or congenital hear problems

bony palpations (18)

• ulna

• styloid process of ulna

• radius

• styloid process of radius

• lister’s tubercle

• anatomic snuff box

• scaphoid/navicular

• lunate

• triquetrum

• pisiform

• hook of hamate

• capitate

• trapezium

• metacarpals

• MCP joints

• phalanges

• carpal transverse arch

• metacarpal transverse arch

posterior palpations (7)

• anatomic snuffbox tendons

  • ext. pollicis longus (top)

  • abductor pollicis longus (side)

  • ext. pollicis brevix (side)

• ext. carpi radialis longus/brevis

• ext. digitorum communis

• ext. indicis

• ext. carpi ulnaris

anterior palpations (9)

• radial artery

• ulnar artery

• carpal tunnel (median nerve and finger flexors)

• tunnel of Guyon (ulnar nerve and artery, flexor carpi ulnaris)

• flexor carpi ulnaris

• palmaris longus

• flexor carpi radialis

• thenar eminence muscles

• hypothenar eminence muscles

ROMs (4 body parts)

• forearm pronation and supination

• wrist flexion, extension, radial and ulnar deviation

• finger flexion and extension, AB- and ADduction

• thumb flexion, extension, ab/adduction, and opposition

examinations other than ROM (3)

• grip (power and precision)

• peripheral nerve innervation

  • radial

  • median

  • ulnar

• dermatomes

  • C6 - lateral forearm, index finger, and thumb

  • C7 - posterior upper arm, anterior forearm, dorsum of hand

  • C8 - medial forearm, pinky, and ring finger

special tests for bony injury (3)

• longitudinal compression/distraction - fracture of digits

• Murphy’s sign - lunate dislocation

• Watson’s test - scaphoid dislocation

special tests for musculotendinous pathologies (5)

• flexor digitorum superficialis - PIP joint

• flexor digitorum profundus - DIP joint

• sweater finger test - avulsion of flexor tendon (jersey finger)

• Finkelstein test - tenosynovitis of thumb tendon (deQuervain’s)

• Bunnel-Littler test - (1) intrinsic muscle tightness, (2) capsular tightness

special tests for neurological pathologies (4)

• Tinel’s sign - carpal tunnel syndrome

• Weber’s two-point discrimination - altered nerve sensation

• Phalen’s test - carpal tunnel syndrome

• Froment’s test - ulnar nerve

special tests for other soft-tissue patholgies (3)

• Allen test - poor circulation

• TFCC/Sharpey’s test - TFCC injury

• finger collateral ligament test - MCL and LCL of finger joints

What must you do for all special tests?

compare bilaterally!

When are you referring? (6)

• gross deformity

• suspected fracture/dislocation

• significant swelling about joints

• significant pain

• joint instability

• loss of motion