Examination of the Wrist and Hand

Question 1

Generally in any history we are asking people about what their dominant hand is and it becomes really important with hand injuries. If someone injures their dominant hand that is usually much (more/less) limiting than if they injure their non dominant hand especially with right handers.

Answer 1

more

Question 2

Most people are using their hands while they are doing something but some of those people are using them for very fine motor skills and others use them for more gross motor skills. So if it is more of a gross movement type thing that is probably a little bit (easier/harder) to deal with than fine motor stuff and we need to consider that when we are rehabbing individuals with hand injuries so that we incorporate the fine motor skills if needed into their particular rehab program. This is why it is important to know the patients occupation or vocation.

Answer 2

easier

Question 3

With common hand injuries you will hear/see the abbreviation FOOSH which stands for what? Essentially they fell with their hand out. It is very common when people lose balance or get knocked over or that sort of thing as a protective response to put their hand out. Most times in those cases the persons’ hand gets forced into (flexion/extension). Depending on how the person falls or how they get knocked down they could be in flexion during the injury. It is helpful to know the MOI if possible in terms of the position their hand was in when they fell. This will help to be able to identify tissues that might have been affected.

Answer 3

Fall on an outstretched shoulder and hand; extension

Question 4

Another large group of injuries to the hand are ___ type injuries. The person gets their hand caught in something or caught between a couple things and it gets crushed. These are usually complex injuries because they involve a lot of structures, soft tissue as well as bone overall. These are often difficult injuries to rehab.

Answer 4

crush

Question 5

A couple things observation wise that you want to look at with the hand is the person’s willingness to use their hand. You pick up a lot of those things when observing your patient when they first come in. How do they take off their coat, are they holding a bag, are they manipulating objects, etc.

Answer 5

Roger that

Question 6

You also want to look at what is referred to as the attitude of the hand. The hand in its’ relaxed position will have (more/less) flexion of the fingers as it moves from radial to ulnar. That is the normal attitude of the hand. If we see deviations from that often times that is suggestive of an injury. You can get peripheral nerve injuries that will change the balance of the muscles in the hand that will change the natural posture of the hand.

Answer 6

more

Question 7

When you have peripheral nerve injuries or crush injuries often times you lose the normal arches of the hand and the hand will appear much (flatter/rounder).

Answer 7

flatter

Question 8

Heberden’s nodes are little swelling that is due to excess bone formation that happens around the (PIP/DIP) joint.
Bouchard’s nodes are the same thing but just relative to the (PIP/DIP) joint. Often times you will see these in older individuals or individuals that have arthritic conditions. The reason they are there is because the person has swelling in their joints. With wearing away of cartilage and that sort of thing and excess force on the bone underneath, you start forming excess bone and that is what makes the joint appear bigger overall.

Answer 8

DIP; PIP

Question 9

A deformity that sometimes you will see in the hand is ulnar drift at the wrist. So often times this is common in individuals who have Rheumatoid arthritis and they will start to get more and more ulnar drift of their fingers towards the (radial/ulnar) side of the wrist. It is a natural disease progression.

Answer 9

ulnar

Question 10

Our wrist and hand in general favor the (radial/ulnar) side of the wrist. If you look at your hand in its natural position, it is normally deviated a little to the ulnar side and that is simply due to the anatomy of the wrist. The radius extends a little bit further distally than the ulna so it just naturally positions itself a little bit in that ulnar position.

Answer 10

ulnar

Question 11

A couple of deformities that you will see in the hand are Swan neck and Boutinniere. These are relatively (common/rare) deformities that you will see. Sometimes you see them in people with no pathology at all, they just have hypermobility or increased laxity in some of the soft tissue structures around the joint itself. Sometimes these are related to arthritic conditions that affect the hand.

Answer 11

common

Question 12

What is the cause of Swan neck?

Answer 12

Damage to the volar plate

Question 13

What are three typical causes of Swan neck?

Answer 13

RA, trauma, and hypermobility

Question 14

Boutonniere is caused by damage to the ___ slip and causes the lateral bands to move to the palm

Answer 14

central

Question 15

What are three causes of Boutonniere’s deformity?

Answer 15

RA, trauma, and hypermobility

Question 16

Swan neck is characterized by hyperextension of the (PIP/DIP) joint and then flexion of the (PIP/DIP) joint.

Answer 16

PIP; DIP

Question 17

Boutonniere is characterized by extension of the (PIP/DIP) joint and flexion of the (PIP/DIP) joint.

Answer 17

DIP; PIP

Question 18

Tenodesis simply refers to the natural passive motion that occurs if you move your wrist into extension that your fingers will flex and if you move your wrist into flexion your fingers will extend. It is the result of passive tension in the tissue. So if I extend my wrist I create more tension in the long (flexors/extensors) of my wrist and hand which will pull my fingers into (flexion/extension).

Answer 18

flexors; flexion

Question 19

If you have tightness of your wrist extensors or of your flexors that may change the normal tenodesis. You should normally see tenodesis. If you do not see any of that or if you see exaggerated tenodesis it could be from (looseness/tightness) of some of those tissues.

Answer 19

tightness

Question 20

From an observation standpoint you want to make sure the colour of the patient’s hand looks normal. Often times people who have poor circulation or with other conditions they may not have normal coloring throughout their hand or when you go to touch their hand the temperature of it does not seem to be normal. You want to look for atrophy and sometimes if there is noticeable atrophy you start thinking about peripheral nerve injuries. You also want to look for excessive sweating of the hand. Sometimes with the hand you will see excess swelling, changes in hair growth and that sort of thing, and often times it might be related to problems with the sympathetic nervous system.

Answer 20

Rodger dodger

Question 21

Some other things you want to look at when observing the hand are scars, wounds, and edema. It is relatively easy to pickup individuals who have swelling in their hand just because it is a pretty confined space. You’ll see swelling in the back of their hand and in the digits of the finger and the digits might look like sausages. Swelling is significant anywhere you see it but it is really significant in the hands because of the confined space that you have there. You have fluid in there that is occupying joint space it makes getting people’s range of motion back to normal more difficult.

Answer 21

Rodger dodger

Question 22

To assess the range of motion of the hand we use the (smaller/larger) goniometers. Generally we are just laying them across the top of the fingers to be able to be able to assess motion. There are a couple of different types of motion that we are going to look at and we referred to these as either ___ joint motions or ____ . I can take this goniometer and lay it over my MP joint, PIP joint, or DIP joint, and get individual measurements for those which is isolated. Or we could also look at composite motion of the hand which would be like asking someone to make a fist and then take ROM measurements over the top of the individual joints that way. Or sometimes what we will do is take a linear measurement using a ruler and take a measurement from a point on the finger to the distal palmar crease that corresponds with your MP joint at your palm of how close the person can get to closing their hand.

Answer 22

smaller; isolated; composite

Question 23

The reason there is two different measurements is because often times when you are taking individual measurements of the joint that is somewhat helpful information but often times it does not tell the whole story. What we are really interested in most times in the hand is can the person close their hand all the way to create a solid grip. Often times you can’t pick that up necessarily. If we know what normal is for all of the joints, we can say that they are pretty close to normal or they are way off from normal so I don’t think they are going to be able to completely close their hand. Often times that linear measurement helps make that a little bit clearer.

Answer 23

Rodger dodger

Question 24

The distal palmar crease is associated with the __ joint and that is what we use to measure in some hand measurements.

Answer 24

MP

Question 25

There isn’t a great bony landmark that we can use on the finger. So generally what is used is where the ____ meets the ___ on the side of the finger. So not on the finger nail itself but that kinda meeting point right there as opposed for going for the tip of the finger which could change based on swelling or the finger nail which could change due to growth or if you cut them.

Answer 25

finger nail; skin

Question 26

There are a couple ways that we try and quantify certain movements of the hand. A great example of that is opposition. So opposition is bringing your thumb and pinky towards one another. There are some goniometric measurements that you can use for this. There are some problems with this in terms of reliability and that sort of thing. So the thing that is used more commonly is referred to as the Kapandji index. What this index does is it uses various points on the hand as a test for how much ____ the individual can perform. If the person can only oppose to the lateral surface of the proximal phalanx that is rated as a 0. If they can get further down on the finger then it is a 1,2, or 3. If they can get to various fingers then it goes up in numbers but the ultimate is to be able to oppose all the way to the base of your pinky which would be considered normal opposition. So often times instead of trying to do a linear measurement between the fingers which isn’t entirely accurate all the time, they’ll just use the Kapandji index to indicate how much opposition they have.

Answer 26

opposition

Question 27

If we think of someone who has difficulty taking their finger and bending it all the way or extending it all of the way, there are a couple of different potential sources of tightness that we can think about here. What are the three things you would think about?

Answer 27

A specific joint, extrinsic tissues, & intrinsic tissues

Question 28

The easiest one to think about is that they might have tightness in any one of the joints of the finger or multiple joints of the finger. They actually have tissue tightness that is happening around those joints and that is limiting their ability to flex or extend. However because of the anatomy of the wrist and hand there are a couple other things that could be causing limitations in their ability to be able to flex their finger. It could be that there is not tightness at all in these joints and the tissue flexibility there is completely normal.

Answer 28

Rodger dodger

Question 29

They can have what is referred to as extrinsic muscle tightness and these are muscles that have their origin outside of the hand itself. So here we are thinking of the long extensors of the wrist and hand or the long flexors of the wrist and hand. So if our extensors are tight they are going to limit (flexion/extension) of the finger and if our long flexors are tight they are going to limit (flexion/extension) of our finger.

Answer 29

flexion; extension

Question 30

Intrinsic tightness is tightness of muscles that have their origin (within/outside) the hand itself. Here we think about muscles of the thenar/hypothenar eminence. They are usually minor players in all of this. Generally the muscle groups that we are most concerned about are the ___ and ____ muscles of the hand. If they have tightness they may limit flexion and extension of the fingers.

Answer 30

within; lumbricals and interossei

Question 31

So from a treatment perspective we would like to be able to figure out where this tightness is coming from because that will ultimately dictate what we have to stretch or what we have to focus our attention on. If it’s the joint(s) then I should be doing work to really increase mobility of those tissues, so I might be doing joint mobilizations, stretches, etc. If it is my extensors or flexors then I need to figure out a way to stretch all of those structures to really increase flexion / extension of my fingers. So the treatment is figuring out where it is coming from.

Answer 31

Roger that

Question 32

If a person is in a cast and everything was immobilized, normally it’ll involve their fingers too and you don’t want them moving that which could move the fracture site and they may end up with tightness in these individual joints.

Answer 32

Roger that

Question 33

For extrinsic tightness it can be the flexors or extensors that cause this. With tightness of those structures you are going to have loss of composite motion. Composite motion is as we start flexing the various structures that might be involved (flexing the wrist, digits, etc), as we do more and more of that we are going to lose overall motion and we are going to encounter restrictions in motion because in doing this we are starting to add tension to the system. As I start to flex my wrist I am adding tension to the (flexors/extensors). As I flex my fingers further I am adding additional tension to them. If we are talking about the flexors, as I (flex/extend) my wrist or (flex/extend) my finger I am starting to add tension to that system. So with extrinsic muscle tightness, as we start adding more tension into the system, we are going to find that there is more (loss of motion/motion gained). But likewise, the way we can sort of figure out if it is extrinsic tightness at play here is we can manipulate some of those joints to see what happens down stream. So we can change the position of the proximal joint and typically it is the wrist and we are going to see what affects it has down stream.

Answer 33

extensors; extend; extend; loss of motion

Question 34

If the extensors are tight it is going to limit flexion of the fingers. If they are tight it is going to make it hard for me to close my hand and create a useful grip. As I flex my wrist and flex my fingers more that is adding more tension into that system. So if I have extrinsic extensor tightness and I flex my wrist more I would expect the flexion of the fingers to (increase/decrease). So as I flex my wrist I am adding more tension to the system so what is going to happen down stream is that there is not going to be as much slack in the tissue to allow the fingers to stretch so often times we are going to (gain/lose) motion in that direction. To make it easier for the fingers to flex you can take your wrist and put it into (flexion/extension) and that should help decrease some of the tension in those tissues and it allows slack into the system which should allow my fingers to bend more.

Answer 34

decrease; lose; extension

Question 35

So one of the ways we distinguish whether or not it is actually extrinsic tightness is at play is to manipulate a (proximal/distal) joint and see what happens down stream. So if I extend my wrist and add slack to the system and all of a sudden the person can bend their fingers further I know that has to be extrinsic muscle tightness causing the inability to close their hand all of the way. Likewise, if I flex the wrist and add more tension to the system and all of a sudden it limits their ability to flex their finger then I also know that that is extrinsic muscle tightness. One case is simply adding tension to see what happens down stream and the other instance is lessening the tension to see what happens down stream and you can do either or.

Answer 35

proximal

Question 36

If nothing changes as you try and manipulate a proximal joint then that means it (is/is not) an extrinsic muscle tightness and the thing you are more suspicious of is tightness of the joints itself or intrinsic tightness, but you have eliminated anything outside of the hand as being the cause of the problem here.

Answer 36

is not

Question 37

If our extrinsic flexors are tight they are going to limit our ability to extend our fingers, open our hand, or lay our hand flat on a surface. So if they are tight I have to extend the wrist to add tension to the system. So if I truly do have extrinsic long flexor tightness then I would expect the fingers to flex more. If I have too much tightness to that system I am going to get more flexing in that system or I won’t be able to extend my fingers as far as what I should. Even if I extend my wrist I should be able to extend my fingers all the way too. So if you have someone who is already limited in their ability to extend their one finger or multiple fingers and they extend their wrist and all of a sudden that limits it even more then I know for sure that they have long flexor tightness that is limiting their ROM. If I flex my wrist that adds slack to the system and we should see that person’s extension increase to make it easier for them to extend their fingers.

Answer 37

Roger that

Question 37

Adding (tension/slack) to the system makes it easier for the person to do the motion they are limited in.

Answer 37

slack

Question 38

Normal PIP flexion is past ___ degrees, maybe close to __ degrees.

Answer 38

90; 100

Question 39

By flexing the wrist we have added tension to the (flexors/extensors) and it is the (flexors/extensors) that we need to be loose in order to have motion in them to be able to flex our PIP joint.

Answer 39

extensors; extensors

Question 40

If someone has limited PIP flexion one of the possible causes for that is that they do not have enough flexibility in their (flexors/extensors) to allow it to bend. So if we add tension to that system by flexing, if it was truly wrist extensor tightness we would expect the ROM to (increase/decrease) in the PIP joint. It would be harder for them to keep the PIP flexed.

Answer 40

extensors; decrease

Question 41

EXAMPLE:
PIP flexion = 20 degrees, wrist in neutral, MP flexed&raquo_space;» PIP flexion = 20 degrees, wrist AND MP flexed. Where is the tightness occurring?

Answer 41

At the joint

Question 42

EXAMPLE: PIP flexion = 20 degrees, wrist in neutral, MP flexed&raquo_space;> PIP flexion = 10 degrees, wrist flexed, MP flexed. Where is the tightness occurring?

Answer 42

At the extrinsic extensors.`

Question 43

To verify if It is actually the extrinsic extensors that are tight you can (flex/extend) the wrist to create slack in the system and you should see the patient be able to flex the PIP joint (more/less).

Answer 43

extend; more

Question 44

EXAMPLE: PIP flexion = 20 degrees, wrist in neutral, MP flexed&raquo_space;»» PIP flexion = 40 degrees, wrist extended, MP neutral. Where is the tightness occurring?

Answer 44

At the extrinsic extensors.

Question 45

-10 degrees of PIP extension means that the PIP is in _ degrees of PIP flexion.

Answer 45

10

Question 46

In anatomical position our fingers should be fully extended which is considered _ degrees of extension.

Answer 46

0

Question 47

Generally we don’t think of our _ or __ joints in the hand going into hyperextension and our __ joint does extend a little bit.

Answer 47

PIP or DIP; MP

Question 48

If we are looking at someone who can’t extend their PIP joint there could be tightness at the joint itself, tightness in the extrinsic wrist (flexors/extensors) which would be pulling the finger down into a flexed position not allowing us to extend all the way.

Answer 48

flexors

Question 49

By flexing the wrist you add some slack to the wrist flexors and if the PIP extends more then that is a perfect indication of (intrinsic/extrinsic) flexor tightness.

Answer 49

extrinsic

Question 50

EXAMPLE: Index finger PIP extension -10 degrees, wrist and MP extended&raquo_space;> Index finger PIP extension 0 degrees, wrist flexed, MP extended. Where is the tightness occurring?

Answer 50

At the extrinsic flexors

Question 51

EXAMPLE: Index finger 35 degrees PIP flexion, MP flexed&raquo_space;> Index finger 35 degrees PIP flexion, MP extended. Where is the tightness occurring?

Answer 51

At the joint itself.

Question 52

When referring to tightness at the joint itself we are referring to any of the soft tissue structures around the joint itself. Whether that is ligament or tendon or things like that. So if it is joint tightness, for our treatment we want to direct the treatment to the joint itself.

Answer 52

Roger dodger

Question 53

So if you went through the testing and you decide that it is extrinsic muscle tightness that is inhibiting the patients ability to close their hand all the way or open their hand all of the way, some ways to try and treat someone with limited ability to flex the PIP joint would be to stretch them into the position they are limited in by putting their wrist into flexion which would wind up the tight (flexors/extensors) or even the MP joint into flexion if you haven’t done that already and then bend their finger as well which would lengthen the entire (flexor/extensor) system.
You may not start out doing all of those things but maybe one of those, and as that improves you are going to gradually add more and more tension to the system (as long as they can take it) and ultimately what we should be able to do is close your hand all the way and be able to flex your wrist. That is considered normal tissue extensibility. The same rules apply for someone limited in extension, just stretch them oppositely.

Answer 53

extensors; extensor

Question 54

If it is only the joint that is tight we can focus on trying to get the joint itself to move more. It does not matter what we do with the wrist or the MP joint (if we are working on the PIP joint). So here we can do some joint mobilizations to get the normal arthrokinematics, specific stretching or even splinting to that particular joint to try and get it to loosen up. If I had to do splinting for extrinsic muscle tightness I might have to have a splint that involves (only the/ the entire) wrist and hand to really stretch someone in that position, so it changes our focus entirely.

Answer 54

the entire

Question 55

You see more problems at the (PIP/DIP) joint than the (PIP/DIP) joint.

Answer 55

PIP; DIP

Question 56

We do do MMT of the wrist and hand, but the fingers is one of those areas where we have to modify the scale a little bit and it is relatively straightforward. We have to modify it because for the most part gravity (does/does not) have a large effect on the fingers. The other thing you need to consider when doing MMT of the fingers is the size of the muscles in comparison to the size of the muscles of the shoulder. It is much smaller so the amount of force that you will apply to them is much less overall.

Answer 56

does not

Question 57

MMT in the hand has limited use. There are generally better ways we can quantify the strength in the hand. One of them is using a grip dynamometer or a pinch dynamometers to assess pinch strength. You’ll ask the patient to squeeze to determine how hard they can squeeze and it will give you a read out in pounds / kilograms. The standard way to do this is to have the patient sitting, arm at their side, elbow bent to _ degrees, and they can self select their wrist position. The standard position on the grip dynamometer is position _. These positions on the device can move the handle further and further away from the body or closer. Position 2 is the second one away form the body. So you ask the patient to squeeze, take a reading, and take an average of _ readings.

Answer 57

90; 2; 3

Question 58

Many times when using the grip dynamometer we measure side to side (left and right) with people. There have been a number of studies that have been done on this and generally people show a pretty (small/large) difference in strength from side to side. So the question becomes whether or not the opposite side is really a good gage of someone’s normal strength. So often times what happens is we will take an assessment of their strength and then do a reevaluation in a couple weeks or a month and use that more as a sign of progress as opposed to getting people to use the other side.

Answer 58

large

Question 59

Another thing you can do with the grip dynamometers is you can test someone in all 5 positions. You start at that number 1 position where their grip is relatively closed and go to the normal position of 2, then 3, 4, and 5. And at 5 it will feel like your finger tips are barely on the handle and you are squeezing. What should happen is if you tested them and graphed those results, you should get a __ shaped curve. And this makes sense. When your hand is really closed you can exert a certain amount of force. You can generally exert the most force when you have proper length tension relationships in the tissue which will be the (middle/end) ranges and as you get way out you can’t generate as much force. What this is sometimes used for is to determine whether or not a patient is actually giving you sincere effort. If you do not get a bell curve it is suggestive that the patient did not give you full effort.

Answer 59

bell; middle