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Patient Management II > Forearm, Wrist, and Hand Evaluation > Flashcards

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

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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
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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
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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
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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)
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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
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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
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8
Q

Describe sensibility testing

A
  • protective for pinprick, touch & temp.
  • necessary for ADLs
  • innervation density tests includes Weber’s 2 point discrimination
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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
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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
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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)
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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)
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13
Q

Ulnar border palpation

A
  • ulnar head & styloid process
  • TFCC
  • hamate (hook of hamate)
  • triquetrum
  • pisiform
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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
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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
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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
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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
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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
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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
Q

When would you not perform joint mobility testing

A
  • if patient has full PROM
26
Q

What are the special tests for carpal tunnel syndrome

A
  • 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
Q

Clinical prediction rule for carpal tunnel syndrome

A
  • 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
Q

Scaphoid fracture tests

A
  • 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
Q

Clinical prediction rule for scaphoid fracture

A
  • 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
Q

1st carpometacarpal (CMC) osteoarthritis tests

A
  • 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
Q

DeQuervain tenosynovitis tests

A
  • Finkelstein test/Eichhoff test (bad test)
32
Q

Triangular fibrocartilage complex (TFCC) tear tests

A
  • Press test
33
Q

Describe hand elevation test

A
  • have patient hold their hands above their head for 60 seconds or until their symptoms are reproduced
  • testing carpal tunnel syndrome
34
Q

Describe tines sign

A
  • tap 4-6 times on proximal carpal ligament
  • (+) = report pain or paresthesias over median nerve distribution
  • bad test
35
Q

Describe Phalen’s test

A
  • 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
Q

Describe reverse Phalen’s test

A
  • 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
Q

Describe carpal compression test

A
  • 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
Q

Describe wrist ratio index

A
  • 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
Q

Describe 1st carpometamarpal grind test

A
  • 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
Q

Describe lever test

A
  • passively move 1st carpometacarpal joint radially & ulnarly to endpoint
  • (+) = reproduction of pain
  • testing 1st carpometacarpal osteoarthritis
  • bad test
41
Q

Describe metacarpophalangeal extension test

A
  • apply isometric resistance againist 1st carpometacarpal extension
  • (+) = reproduction of pain
  • testing 1st carpometacarpal osteoarthritis
  • good for ruling in test
42
Q

Describe thumb adduction maneuver

A
  • 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
Q

Describe thumb extension maneuver

A
  • 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
Q

Describe Finkelstein test/Eichhoff test

A
  • 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
Q

Describe press test

A
  • 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

Patient Management II (17 decks)

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