Forearm, Wrist, and Hand Evaluation Flashcards
1
Q
Describe the possible injuries based on pain location
A
Radial pain:
- Trauma: scaphoid
- Gradual onset: DeQuervains Tenosynovitis
- Pain slightly more proximal: intersection syndrome
Posterior pain:
- radial carpal arthritis
- ganglion cyst
Ulnar pain:
- TFCC
Anterior pain:
- carpal tunnel syndrome
Digit or metacarpal pain:
- Trauma: fracture
- Gradual onset: arthritis
2
Q
Red flags for history
A
- no incident or accident
- glove like numbness
- are the symptoms constant/unrelenting
- multiple dermatomes
- sudden onset of severe pain
- interrupting sleep/worse at night
3
Q
Initial hypotheses based on patient history
A
- pain over radial styloid process with gripping activities: possible DeQuervain syndrome
- reports insidious onset numbness & tingling in first 3 fingers, pain worse with positioning at night: possible carpal tunnel syndrome
- reports paresthesias over dorsal aspect of ulnar border of hand digits 4-5: possible ulnar nerve compression at the tunnel of Guyon
- reports inability to extend MCP of IP joint: possible Dupuytren conjecture or trigger finger
- reports falling on hand with wrist hyper extended, reports pain with loading of wrist: possible scaphoid fracture/possible carpal instability
4
Q
History suggesting carpal tunnel syndrome
A
- age >40
- symptoms wake patient
- bilateral symptoms
- numbness & tingling digits 1-3
- reports decreased sensation digits 1-3
- shaking hands improves symptoms
- reports dropping objects
- symptoms exacerbated with gripping objects
5
Q
Patient self assessments
A
- DASH: disabilities of the arm, shoulder, & hand
- PRWHE: patient rated wrist & hand evaluation
- MHQ: Michigan hand questionnaire
- Brigham & women’s hospital hand severity scale & CTQ (carpal tunnel questionnaire)
6
Q
When is pathology suspected in the wrist & hand
A
- disruption of bony long axis: displaced fracture (acute); malunion (chronic)
- joint angulation or deformity: fracture, joint contracture, or dislocation
- nodule protruding from wrist or dorsal hand: ganglion cyst
- palmar nodules with or without evidence of collagenous cords in the palmar fascia upon finger extension: Dupuytren disease
- nodule just proximal to A1 pulley: trigger finger
- ape or claw hand: median or ulnar nerve lesion, respectively
- thenar atrophy: carpal tunnel syndrome
- hypothenar atrophy: ulnar nerve lesion
- wrist drop: radial nerve lesion
- drooping of the distal phalanx: mallet finger
- loss of DIP joint flexion: flexor digitorum profundus (FDP) tendon avulsion or laceration
- Bouchard (PIP joint) or heberden (DIP joint) nodes: osteoarthritis
- Boutonniere deformity/Swan neck deformity: rheumatoid arthritis
7
Q
Describe Weber’s (Moberg’s) two point discrimination test
A
- purpose: attempt to find the minimal distance which the patient can determine between two stimuli
- therapist applies pressure on two adjacent points of the patients fingertips with a paper clip
- no blanching of the skin should occur when points are tested
- patient should not see the area being tested
- the distance between the 2 points should be increased or decreased depending on the patients response
- patient must be accurate on 7 of 10 trials before distance is narrowed
8
Q
Describe sensibility testing
A
- protective for pinprick, touch & temp.
- necessary for ADLs
- innervation density tests includes Weber’s 2 point discrimination
9
Q
Describe sensibility capacity
A
- sees if detection is present
- innervation/discrimination for sharp versus dull and light touch versus pressure
- can the patient recognize/identify different objects
10
Q
Describe the Allen test
A
- is a vascular test
-patency of the radial & ulnar arteries - compress both arteries while patient makes a fist 3-5 times until palm is pale
- release compression on one artery & note the time it takes for normal color to return
- repeat with other artery
11
Q
Functional screen for the hand
A
- opposition of the thumb to each finger (median nerve)
- hook fist: fingertips to MCP
- straight fist: fingertips to base of hand
- full fist
- cylindrical (holding can) and spherical (holding a ball) grip
- key/lateral tip (ulnar nerve): place thumb on side of index finger
- 3 point pinch (median nerve)
12
Q
Radial border palpation
A
- radial styloid process (proximal border snuff box)
- scaphoid (floor of snuff box)
- trapezium (floor of snuff box)
- first CMC
- pisiform
- EPB and APL (radial border of snuff box)
- EPL (ulnar border of snuff box)
13
Q
Ulnar border palpation
A
- ulnar head & styloid process
- TFCC
- hamate (hook of hamate)
- triquetrum
- pisiform
14
Q
Palpation with pain on radial side
A
- Radial styloid: fracture, DeQuervain syndrome, or arthritis
- Scaphoid (anatomical snuff box): fracture, avascular necrosis, or scapholunate ligament injury
- Thumb (1st MCP, phalanges, MP, & IP): fracture & sprain/tendon injury
- 1st CMC: arthritis
- First dorsal compartment (APL & EPB): DeQuervain syndrome
15
Q
Palpation with pain on dorsal side
A
- Lister tubercle (dorsal of radius where EPL makes 45 degree turn): fracture or EPL tendonitis
- Lunate: Kienbock disease, dislocation, subluxation, instability, or fracture
- Capitate: fracture, subluxation, or instability
- 2nd, 3rd, & 4th fingers MC, phalanges CMC: fracture or ligament injury
- Scapholunate joint: scapholunate ligament injury or ganglion cyst
- 2nd & 4th compartments (ECRB/ECRL & ED/EI tendons): tenosynovitis or impingement under extensor retinaculum
16
Q
Palpation with pain on ulnar side
A
- Ulnar styloid & ulnar head: fractured distal radioulnar joint injury
- Triquetrum: fracture or TFCC injury
- Hamate: fracture
- 5th digit (MC, phalanges, and CMC): fracture, sprain/ligament injury, or volar (palm) plate injury
- Distal RU (radioulnar) joint: arthritis, instability, or TFCC injury
17
Q
Palpation with pain on volar (palmer) side
A
- Scaphoid tubercle: fracture
- Pisiform: fracture or pisotriqutral arthritis
- Hook of hamate: fracture
- Distal ulnar tunnel: ulnar nerve syndrome
- Wrist & finger flexor tendons (proximal & distal to carpal tunnel): tenosynovitis, trigger finger, tendon rupture, or Dupuytren disease
18
Q
Describe the Bunnell-Littler/intrinsic plus test
A
- used to determine cause of PIP flexion restriction
- hold MCP joint in slight extension & passively flex the PIP: increased flexion = intrinsic muscle restriction or continued limited flexion = capsule
19
Q
Describe the Jamar dynamometer/testing grip strength
A
- maximum force (tolerated) is required
- alternate testing hands to avoid fatigue
- record the mean of 3 trials
- typically a 10% difference between dominate & on-dominate hands
20
Q
3 types of pinch grip strength
A
- 3 point chuck (pulp to pulp/palmar pinch)
- lateral or key (pulp to side)
- tip (tip to tip/opposite digits)
21
Q
Measuring quantity of movement
A
- Normal: 3
- Hypomobile: 0-2 (anklosis/fused to slight decreased movement)
- Hypermobile: 4-6 (slight increased movement to complete instability)
22
Q
What is the starting/resting position of the wrist for joint mobility testing
A
- slight flexion and ulnar deviation
23
Q
Describe how to test for end feel
A
- go to first stop/marked resistance
- push further gently
- normal end feels are pain free: soft, firm. or hard
- abnormal end feels: boggy (swelling), sudden end feel with a rebound (muscle spasm), or empty (pain)
24
Q
What glides increased what motions
A
- posterior/dorsal glide to improve wrist flexion
- anterior/palmar glide to improve wrist extension
- ulnar glide to improve radial deviation
- radial glide to improve ulnar deviation
- anterior/palmar glide to improve any finger flexion
25
When would you not perform joint mobility testing
- if patient has full PROM
26
What are the special tests for carpal tunnel syndrome
- Hand elevation test (hold hands above head for 1 min or until Sx are reproduced)
- Tinel sign (tap median nerve 4-5 times) +LR 1
- Phalen sign (60 sec hold) +LR 1.3 -LR 0.58
- Reverse Phalen's/wrist extension test (+LR 5 -LR 0.29)
- Carpal compression test (wrist in neutral with 30 sec hold) +LR 0.91 -LR 1.2
- Wrist ratio index greater than 0.67 (narrow part divided by wide part) +LR 1.3 -LR 0.29
- Sensory loss at pad of thumb
27
Clinical prediction rule for carpal tunnel syndrome
- 4 out of 5 symptoms = +LR 18.3
- Brigham & Women's Hospital Hand Severity scale score >1.9
- Wrist ratio index >0.67
- report of shaking hand provides symptom relief
- diminished sensation on thumb pad
- age >45
28
Scaphoid fracture tests
- anatomical snuff box tenderness (good at ruling out test)
- pain with longitudinal compression of the thumb (bad test)
- pain with supination against resistance (good test)
29
Clinical prediction rule for scaphoid fracture
- all 4 positive = 91% risk of fracture
- male gender
- sports injury
- anatomic snuff box pain on ulnar deviation of wrist within 72 hours of injury
- scaphoid tubercle tenderness at 2 weeks
- all patients that did not have anatomic snuff box pain on ulnar deviation within 72 hours of injury did not have a fracture
30
1st carpometacarpal (CMC) osteoarthritis tests
- first CMC grind test (good at ruling in test)
- lever test (bad test)
- metacarpaphalangeal extension test (good for ruling in test)
- thumb adduction maneuver
- thumb extension maneuver
31
DeQuervain tenosynovitis tests
- Finkelstein test/Eichhoff test (bad test)
32
Triangular fibrocartilage complex (TFCC) tear tests
- Press test
33
Describe hand elevation test
- have patient hold their hands above their head for 60 seconds or until their symptoms are reproduced
- testing carpal tunnel syndrome
34
Describe tines sign
- tap 4-6 times on proximal carpal ligament
- (+) = report pain or paresthesias over median nerve distribution
- bad test
35
Describe Phalen's test
- ask patient to flex both wrist to 90 degrees with dorsal aspects held together
- hold for 60 seconds
- (+) = pain or paresthesias in at least one digit innervated by median nerve
- testing carpal tunnel syndrome
- bad test
36
Describe reverse Phalen's test
- ask patient to extend both wrist to 90 degrees with palmar aspects held together
- hold for 60 seconds
- (+) = pain or paresthesias in at least one digit innervated by median nerve
- testing carpal tunnel syndrome
- okay test
37
Describe carpal compression test
- provide compression over median nerve at carpal tunnel with 2 fingers for 30 seconds
- (+) = pain, paresthesia, or numbness produced
- testing carpal tunnel syndrome
- bad test
38
Describe wrist ratio index
- measure the anteroposterior wrist width and the mediolateral wrist width at the distal wrist crease
- calculate ratio by dividing the anteroposterior width by the mediolateral width in centimeters
- (+) = > 0.67
- testing carpal tunnel syndrome
- bad test
39
Describe 1st carpometamarpal grind test
- compress the 1st metacarpal into the trapezium using an axial load & rotate the metacarpal
- (+) = reproduction of the patient's pain
- testing 1st carpometacarpal osteoarthritis
- good at ruling in test
40
Describe lever test
- passively move 1st carpometacarpal joint radially & ulnarly to endpoint
- (+) = reproduction of pain
- testing 1st carpometacarpal osteoarthritis
- bad test
41
Describe metacarpophalangeal extension test
- apply isometric resistance againist 1st carpometacarpal extension
- (+) = reproduction of pain
- testing 1st carpometacarpal osteoarthritis
- good for ruling in test
42
Describe thumb adduction maneuver
- patient elbow should be flexed to 90 degrees & forearm in neutral
- PT should prevent ulnar deviation with one hand while the other hand presses the 1st metacarpal head until it lies parallel to the index metacarpal
- (+) = reproduction of pain
- testing 1st carpometacarpal osteoarthritis
43
Describe thumb extension maneuver
- patient elbow should be flexed to 90 degrees & forearm in neutral
- PT should prevent ulnar deviation with one hand while the other hand is on the radial aspect of the distal 1st metacarpal & extends thumb until it is parallel to the palm
- (+) = reproduction of pain
- testing 1st carpometacarpal osteoarthritis
44
Describe Finkelstein test/Eichhoff test
- have patient place thumb into flexion & flex there fingers along their thumb
- have patient ulnarly deviate wrist
- PT applies overpressure over index finger
- (+) = pain & limited ROM
- testing DeQuervain tenosynovitis
- bad test
45
Describe press test
- ask patient to push themself up from a chair with palms flat/wrists in extension
- (+) = pain along ulnar side of wrist
- testing triangular fibrocartilage complex (TFCC) tear
