Wrist and hand examination

Examination, evaluation & Assessment of Wrist and Hand

1. Examination, evaluation & Assessment of Hand and Wrist Dr. Abid Ullah PT Lecturer FIMS Abbottabad Email: [email protected]

2. OBJECTIVES Review the clinical anatomy and physical exam of the wrist and hand Formulate a pathoanatomic diagnosis in the clinical setting Discuss common clinical conditions that can be elicited from the physical exam

3. INTRODUCTION: Hand and Wrist Series of complex, delicately balanced joints Function is integral to every act of daily living Most active portion of the upper extremity

4. INTRODUCTION The least protected joints Extremely vulnerable to injury Difficult and complex examination Diagnosis often vague If no fracture = “wrist strain or sprain” Bilateral comparison useful

5. wrist consist of the distal radius, scaphoid (S) lunate (L) triquetrum (Tri) pisiform (P) trapezium (Tm) trapezoid (Tz) capitate (C) and hamate (H). she Looks Too Pretty Try To Catch her

6. Bony Anatomy Phalanges: 14 Sesamoids : 2 Metacarpals: 5 Carpals Proximal row: 4 Distal row: 4 Radius and Ulna Lister’s tubercle

7. Radiocarpal Joint (RC) joint is enclosed in a loose but strong capsule. The biconcave articulating surface is the distal end of the radius and radioulnar disk; it is angled slightly volarward and ulnarward. The biconvex articulating surface is the combined proximal surface of the scaphoid, lunate, and triquetrum. the convex proximal row of carpals slides in the direction opposite the physiological motion of the hand.

8. Bony Anatomy

9. Midcarpal Joint a compound joint between the two rows of carpals. The combined distal surfaces of the scaphoid, lunate , and triquetrum articulate with the combined proximal surfaces of the trapezium, trapezoid, capitate, and hamate.

10. 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

11. HISTORY Age Handedness Chief complaint Occupation Previous injury Previous surgery Sx related to specific activities What exacerbates What improves Frequency Duration

12. Range of motion The wrist complex is biaxial motions of extension/flexion around coronal axis ulnar deviation/radial deviation around an anteroposterior axis. Pronation / supination may found especially at the radiocarpal joint Normal ranges are 65 to 85 of flexion (average max 70) 60 to 85 of extension (ave… 70) 15 to 21 of radial deviation (ave… 20) 20 to 45 of ulnar deviation (ave…40)

13. PHYSICAL EXAM Inspection Palpation Range of Motion Neurologic Exam Special Tests

14. Surface Features of Forearm and Wrist Ulna Radius Brachioradialis muscle Flexor carpi radialis muscle Palmaris longus muscle Flexor digitorum superficialis muscle Flexor carpi ulnaris muscle Radial artery Pisiform bone Wrist creases Copyright 2011, John Wiley & Sons, Inc.

15. Ulnar styloid/distal ulna.  Medial aspect of the distal ulna Site of attachment of ulnar collateral ligament of the wrist Fractures of the ulnar styloid can lead to instability of the distal radioulnar joint (DRUJ). Palpation, supination, pronation Radial styloid.   Lateral aspect of distal radius Site of attachment for the brachioradialis tendon and radial collateral ligament of the wrist.

16. Surface Features of the Forearm and Wrist Copyright 2011, John Wiley & Sons, Inc.

17. Copyright 2011, John Wiley & Sons, Inc. Surface Features of the Forearm and Wrist

18. Copyright 2011, John Wiley & Sons, Inc. Surface Features of the Forearm and Wrist

19. Surface Features of the Hand Knuckles Dorsal venous network of the hand (dorsal venous arch). Tendon of extensor digiti minimi muscle Tendons of extensor digitorum muscle

20. Copyright 2011, John Wiley & Sons, Inc.

21. Surface Features of the Hand

22. Surface Features of the Hand

23. INSPECTION Observe upper extremity as patient enters room Examine hand in function Deformities Attitude of the hand

24. INSPECTION Palmar Surface Creases Thenar and Hypothenar Eminence Arched Framework Hills and Valleys Web Spaces

25. Cascade sign Assure all fingers point to scaphoid area when flexed at PIPs

26. Volar Wrist Musculature Six muscles have tendons crossing the volar aspect of the wrist and, therefore, are capable of creating a wrist flexion movement

27. These are Palmaris longus (PL), flexor carpi radialis (FCR), Flexor carpi ulnaris (FCU), the flexor digitorum superficialis (FDS), flexor digitorum profundus (FDP), the flexor pollicis longus (FPL) muscles. first three of these muscles are primary wrist muscles. last three are flexors of digits with secondary actions at wrist

28. Figure 9-13 ■ The dorsally located extensor tendons pass beneath the extensor retinaculum, where the tendons are compartmentalizd. From the radial to the ulnar side, APL, EPB muscles share a compartment; ECRB ,ECRL muscles share a compartment (EPL) muscle has a compartment of its own; the four tendons of (EDC) share a compartment with the extensor (EIP) (EDM) and the extensor carpi ulnaris (ECU) has its own compartment

29. INSPECTION of Dorsal Hand and Wrist Hills and Valleys Height of metacarpal heads Finger nails Pale or white=anemia or circulatory Spoon shaped=fungal infection Clubbed=respiratory or congenital heart Deformities

30. Ganglion Cystic structure that arises from synovial sheath Discrete mass Dull ache Dorsal or Volar aspect

31. Boutonniere Deformity Tear or stretch of the central extensor tendon at PIP Note: unopposed flexion at PIP Extension at DIP Trauma or inflammatory arthritis

32. Osteoarthritis Heberden’s nodes: DIP Bouchard’s nodes: PIP

33. Rheumatoid Arthritis MCP swelling Swan neck deformities Ulnar deviation at MCP joints Nodules along tendon sheaths

34. Mallet Finger Hyperflexion injury Ruptured terminal extensor mechanism at DIP Incomplete extension of DIP joint or extensor lag Treatment: stack splint

35. Dupuytren’s Contractures Palmar or digital fibromatosis Flexion contracture Painless nodules near palmar crease Male> Female Epilepsy, diabetes, pulmonary dz, alcoholism

36. Carpal Tunnel The median nerve and the finger flexion tendons lie within the carpal tunnel. This is a common site of compression neuropathy.

37. Carpal Tunnel

38. Guyon’s Canal (Ulnar Tunnel) The ulnar nerve and artery lie within Guyon’s tunnel. This is also a common site of compression neuropathy.

39. Guyon’s Canal (Ulnar Tunnel)

40. Carpal Tunnel Syndrome Carpal tunnel syndrome is a compression neuropathy of the median nerve. Compression occurs under the flexor retinaculum at the wrist.

41. Carpal Tunnel Syndrome

42. Carpal Tunnel Syndrome Clinical Signs and Symptoms Loss of sensation of the tips of the first three fingers Hand and wrist pain Weakness of grip

43. Tinel’s Wrist Sign Procedure: Patient’s hand supinated . Stabilize the wrist with one hand. With your opposite hand, tap the palmar surface of the wrist with a neurological reflex hammer. Rationale: Tingling along the distribution of the medial nerve indicates carpal tunnel syndrome. The cause could be any of the following: inflammation of the flexor retinaculum , anterior dislocation of the lunate bone, arthritic changes, or tenosynovitis of the flexor digitorum tendons.

44. Tinel’s Wrist Sign

45. Phalen’s Test Procedure: Flex both wrist and approximate them towards each other. Hold for 60 seconds. Rationale: When both wrists are flexed, the flexor retinaculum provides increased compression of the medial nerve in the carpal tunnel. Tingling in the distribution of the median nerve (thumb, index finger, middle finger, and medial half of ring finger) indicates carpal tunnel syndrome.

46. Phalen’s Test

47. Reverse Phalen’s Test Procedure: Instruct the patient to extend the affected wrist and have him grip your hand. With your opposite thumb, press on the carpal tunnel. Rationale: Extending the hand and providing pressure over the carpal tunnel further constricts the tunnel. Tingling may indicate compression of the medial nerve.

48. Reverse Phalen’s Test

49. Ulnar Tunnel Syndrome The ulnar nerve travels through the tunnel of Guyon and innervates the muscles of the little and ring fingers. Ulnar nerve syndrome is a compression neuropathy of the ulnar nerve.

50. Guyon’s Canal (Ulnar Tunnel)

51. Ulnar Tunnel Syndrome Clinical Signs and Symptoms Pain over the little and ring finger Weakness of grip Difficulty with finger spreading Claw hand

52. Ulnar Tunnel Triad Procedure: Inspect and palpate the patient’s wrist, looking for tenderness over the ulnar tunnel, clawing of the ring finger, and hypothenar wasting. Rationale: All of these signs are indicative of ulnar nerve compression possibly in the tunnel of Guyon.

53. Ulnar Tunnel Triad

54. Stenosing Tenosynovitis Stenosing tenosynovitis in the wrist affects the tendon and sheath of the abductor pollicis longus and extensor pollicis brevis. It is also termed de Quervain’s or Hoffman’s disease. Swelling of the tendons and thickening of the sheaths that they pass through is due to an overuse condition of the wrist and thumb.

55. Stenosing Tenosynovitis Clinical Signs and Symptoms Painful wrist and thumb during movement Swelling over the radial styloid Tendons and sheath tender to palpation

56. Stenosing Tenosynovitis

57. Finkelstein’s Test Procedure: Instruct the patient to make a fist with the thumb across the palmar surface of the hand and to stress the wrist medially. Rationale: Making a fist and stressing it medially will stress the abductor pollicis longus and extensor pollicis brevis tendons. Pain in the distal styloid process of the radius indicates stenosing tenosynovitis of the tendons (de Quervain’s disease).

58. Finkelstein’s Test