W13.1 Examination of the Wrist & Hand

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How many carpal bones are in the wrist? Name them

8

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1. Scaphoid

2. Lunate

3. Triquetrum

4. Pisiform

5. Trapezium

6. Trapezoid

7. Capitate

8. Hamate

What joint is responsible for pronation and supination at the wrist/forearm region?

Distal radioulnar joint (DRUJ)

What is the wrist joint proper called?

Radiocarpal joint

What does the radiocarpal joint include?

An articular disc

What joint lies between the proximal and distal carpal rows?

Midcarpal joint

Which metacarpal is the central pillar and most stable?

3rd metacarpal

Which CMC joints are highly mobile?

1st, 4th, and 5th

What do extrinsic ligaments of the wrist connect?

Forearm to carpal bones

What do intrinsic ligaments of the wrist connect?

Carpal to carpal

What does TFCC stand for?

Triangular fibrocartilage complex

Where is the TFCC located?

In the ulnocarpal space between the distal ulna and the first carpal row

What structures are included in the TFCC?

• Articular disc

• Capsular ligaments of the DRUJ

• Ulnar collateral ligament

What is the primary stabilizer for pronation and supination at the wrist?

TFCC

How are hand muscles classified?

Extrinsics and intrinsics

Where do extrinsic and intrinsic hand muscles originate?

• Extrinsic → Forearm

• Intrinsic → Hand

What is passive insufficiency?

A muscle on stretch or lengthened has a decreased ability to produce force

What is active insufficiency?

A muscle on slack or shortened has a decreased ability to produce force or torque

What muscle position is optimal for force production?

Mid-position

What three nerves supply the hand?

Median, ulnar, and radial nerves

In the hand, which nerve is sensory only?

Radial nerve

In the hand, which nerves have both motor and sensory components?

Median and ulnar nerves

What proximal regions should every hand patient be screened for?

• Cervical spine

• Shoulder

• Elbow

Why is an upper quarter screen important in hand patients?

To rule out proximal issues manifesting distally

What are the minimum requirements of the upper quarter screen for a hand patient?

• History of pain elsewhere

• AROM of the upper quarter

• A neuroscreen of C4-T1 dermatomes, myotomes, and reflexes

What specific history factor in wrist/hand evaluation helps point toward certain diagnoses?

Age

Why are occupation and hobbies important in wrist/hand history taking?

They help identify repetitive movements in sports or work

What onset pattern suggests trauma vs insidious wrist/hand problems?

• Sudden → trauma/fall

• Gradual → insidious

What symptoms in wrist/hand history may suggest nerve involvement?

Numbness, tingling, or paresthesia, especially at night

What should you ask about alleviating factors in a wrist/hand history?

Positions of the hand or upper quarter that relieve symptoms

What common deformities should be observed in a hand exam?

• Mallet finger

• Claw hand

• Ulnar drift

What standard grip patterns should be screened in a hand exam?

• Hook

• Cylinder

• Fist

• Spherical

What is a three-jaw chuck pinch?

• Thumb, index, and middle finger pinch

• Ex: holding a pencil

What is a lateral or key pinch?

• Thumb against the side of the index finger

• Ex: holding a key or cards

What is a tip-to-tip pinch?

• Tips of fingers touching in an OK position

• Ex: holding a needle

What is the intrinsic plus position?

Intrinsics firing and extrinsics silent

What is the extrinsic plus position?

Extrinsics firing and intrinsics silent

What hand motion screen is demonstrated with the elbow supported on the table and palm facing out?

1. Abduction

2. adduction

3. lumbrical

4. hook

5. straight fist

6. closed fist with thumb wrapped

7. pulp-to-pulp

8. tip-to-tip

9. closed thumb

What joint resting position is typical for the radiocarpal joint?

Neutral with slight ulnar deviation

What is the close-packed position of the radiocarpal joint?

Extension

What is the capsular pattern of the radiocarpal joint?

Flexion and extension equally limited

What is the end feel of the radiocarpal joint?

Firm/hard due to bony impact

What joint resting position is typical for the intercarpal joint?

Neutral or slight flexion

What is the close-packed position of the intercarpal joint?

Extension

Does the intercarpal joint have a capsular pattern?

No

What joint resting position is typical for the midcarpal joint?

Neutral or slight flexion with ulnar deviation

What is the close-packed position of the midcarpal joint?

Extension with ulnar deviation

What is the capsular pattern of the midcarpal joint?

Flexion and extension equally limited

What is the resting position of the thumb CMC joint?

Midway between abduction/adduction and flexion/extension

What is the close-packed position of the thumb CMC joint?

Full opposition

What is the capsular pattern of the thumb CMC joint?

Abduction and extension

What is the capsular pattern of the finger CMC joints?

Equal limitation in all directions

What is the resting position of MCP joints?

Slight flexion

What is the close-packed position of the finger MCP joints?

Flexion

What is the close-packed position of the thumb MCP joint?

Full opposition

What is the capsular pattern of the MCP joints?

Flexion more limited than extension

What is the end feel of the MCP joints?

Firm due to the volar plate

What is the resting position of IP joints?

Slight flexion

What is the close-packed position of IP joints?

Full extension

What is the capsular pattern of IP joints?

Flexion and extension

What is the end feel of IP joints?

Firm due to capsule/volar plate

What is the end feel for wrist extension and radial deviation?

Firm or hard due to bony impact of the radial styloid on carpals

What is the end feel for wrist flexion?

Tissue stretch

During wrist flexion overpressure, where should force be applied?

Through the 3rd digit

Why should pressure not be applied through the 1st or 5th digits during wrist flexion overpressure?

It causes excessive CMC rotation and does not isolate wrist motion

What is the end feel for ulnar deviation?

Firm, but without the same bony stop as radial deviation

Why does ulnar deviation lack the same bony stop as radial deviation?

The distal ulna is shorter

How can composite finger flexion be measured?

Distance from fingertip to distal palmar crease with a ruler

How can CMC opposition be measured?

Distance from thumb tip to the 5th metacarpal joint

What is the standard arm position for grip dynamometry?

Arm at side and elbow flexed to 90 degrees

What handle position is usually used for grip dynamometry?

Mid-position, usually the 3rd notch

What is the standard protocol for grip dynamometry?

Average of 3 trials alternating hands

What difference is normal between dominant and nondominant hands in grip strength?

5 to 10 percent

What test-retest grip strength discrepancy suggests inconsistent effort?

Greater than 20 percent

At what age does grip strength typically peak?

Early to middle adulthood

What reflexes are commonly included in the sensory exam for the upper quarter/hand?

Biceps, triceps, and brachioradialis

What is the starting distance for static 2-point discrimination?

15 mm

What is normal static 2-point discrimination?

Less than 6 mm

What is fair static 2-point discrimination?

7 to 10 mm

What is poor static 2-point discrimination?

11 to 15 mm

What is normal moving 2-point discrimination?

2 to 5 mm

Which type of 2-point discrimination is more functionally correlated and predicts recovery better?

Moving 2-point discrimination

What do Semmes-Weinstein monofilaments assess?

Light touch perception

What Semmes-Weinstein monofilament value indicates normal sensation?

4.08 or 1 g

What Semmes-Weinstein monofilament value indicates protective sensation?

5.07 or 10 g

What pulses should be assessed in the wrist/hand circulation exam?

Brachial, radial, and ulnar pulses

What circulation tests are commonly used in a wrist/hand exam?

Allen’s test and capillary refill

How is edema quantified with volumetrics?

Water displacement in room-temperature water

How much water displacement suggests swelling on volumetrics?

30 to 50 mL

What tape measure method is commonly used for hand edema and is less messy than volumetrics?

Figure-of-eight measurement

Describe the figure-of-eight path for hand edema measurement.

Ulnar styloid to volar wrist crease to dorsal 5th MCP to volar 2nd MCP and back dorsally to ulnar styloid

What functional tests assess timed hand manipulation?

Jebsen-Taylor, Box and Block, Moberg’s Pick-up, and 9-hole peg tests

What joint play motions are assessed at the wrist?

Distraction, dorsal glide, volar glide, lateral glide, and medial glide

Which wrist glide improves flexion?

Dorsal glide

Which wrist glide improves extension?

Volar glide

Which wrist glide improves ulnar deviation?

Lateral glide

Which wrist glide improves radial deviation?

Medial glide

What joint play motions are assessed at the finger and thumb MCP/IP joints?

Volar, dorsal, and lateral glides at the MCP

What joint play is assessed at the intermetacarpal joints?

AP rocking

What joint play motions are assessed at the thumb CMC?

Volar/dorsal, medial/lateral, internal/external, distraction/compression

Why is scar mobility assessed in a wrist/hand exam?

Scar adhesions can severely limit tendon excursion and finger movement