Hand and Wrist Exam Flashcards
What important question needs to be asked when presented with an arm/hand injury?
Dominate hand
What are the four (five?) principle mechanisms of injury?
Throwing Weight bearing Twisting Impact High energy vs low energy injury
What are common symptoms?
Pain in the wrist or hand
Numbness or tingling (paresthesia) in the wrist or fingers
Loss of movement and stiffness
Deformities
What are the components of the PE?
Inspection Palpation Range of Motion Neurologic Exam Special Tests
What are the components of inspection?
- Observe upper extremity as patient enters room
- Examine hand in function
- Deformities
- Attitude of the hand: how the hand/arm is being held
How is the dorsal hand and wrist inspected?
- Hills and Valleys
- Height of metacarpal heads
- Finger nails
A. Pale or white=anemia or circulatory
B. Spoon shaped=fungal infection
C. Clubbed=respiratory or congenital heart - Deformities
How is the palmar hand and wrist inspected?
- Creases
- Thenar and Hypothenar Eminence
- Hills and Valleys
- Web Spaces
What is the cascade sign?
Assure all fingers point to scaphoid area when flexed at PIPs
Document as no rotational abnormalities
How is the motor function of the hand assessed?
- Grasp/grip strength
2. Pinch strength
How is the sensory function of the hand assessed?
- Stereognosis (size, shape)
- Pinprick test
- Light touch test
- Two-point discrimination
What is included in rapid assessment of hand function?
- Space and stability
- Open and close
- Flex digits
- Extend digits
- Adduct, Abduct - Pinch, opposition, sensation of digits
Test the ROM of which tendons?
Flexor Digitorum Superficialis (FDS)
Extend all other digits to isolate
Test flexion of each finger then test FDP
Flexor Digitorum Profundus (FDP)
True false: elbow and wrist equallt participate in pronation ad supination
True
How is finger ROM tested?
Finger flexion
Should be able to touch finger pad to palm
Finger extension
How is wrist ROM tested?
Radial Deviation – toward the radius Ulnar Deviation – toward the ulna Flexion Extension Supination Pronation
What nerves innervate the hand?
Ulnar
Median
Radial
LOOK AT PICTURES
Which finger is innervated by C6?
Thumb and forefinger
Which finger is innervated by C7?
Middle finger
Which finger is innervated by C8?
Ring and pinkie finger
What functions are associated with each Cervical nerve?
Wrist Ext – C6 Wrist Flex – C7 Finger Ext – C7 Finger Flex – C8 Finger Abd – T1 Finger Add – T1
What three “hooks’ of the wrist bones are palpable?
- pisiform: ulnar side
- Hook of hamate: easy to feel on dorsal)
- Scaphoid tubercle (under thumb)
What landmarks need to be palpated on the wrist?
- Radial Styloid
- Scaphoid
- 1st MC/Trapezium jt
- Lunate
- Lister’s Tubercle
- Ulnar Styloid
- Triquetrum
- TFCC
Define Thumb CMC joint arthritis tests
- Painful pinch or grasp
- “Grind Test”
Axial pressure to thumb while palpating CMC joint
How is the lunate bone in the wrist palpated?
Flexion of the wrist facilitates palpation of the lunate
Define Kienbock’s disease
- Idiopathic osteonecrosis of lunate
- Stress or compression fracture of the lunate
A. Disruption of blood supply with collapse and secondary fragmentation - Pain and stiffness of the wrist in the ABSENCE of TRAUMA
Define Scaholunate dissociation
- Diagnosis often missed
- Pain, swelling, and decreased ROM
- Pressure over scaphoid tuberosity elicits pain
- Greatest pain over dorsal scapholunate area, accentuated with dorsiflexion
- X-ray shows widening of scapholunate joint space by at least 3 mm
Define TFCC Triangular fibrocartilage complex injuries
- Thickened pad of connective tissue that is the major ligamentous stabilizer of the distal radioulnar joint and the ulnar-carpus joint
- Injury from compression between lunate and head of ulna
A. Breaking fall with hand
B. Rotational forces-racket and throwing sports
What are the sxs of TFCC injury?
- Ulnar sided wrist pain, swelling, loss of grip strength
- “Click” with ulnar deviation
- Point tenderness distal to ulnar styloid
- TFCC load test
What are the neuro muscle testings of the wrist and figners?
WRIST:
EXT C6
FLEX C7
FINGERS: EXT C7 FLEX C8 ABD T1 ADD T1
How is the ulnar nerve tested?
little finger movement and resistance to movement
How is the median nerve tested?
Thumb: move up, down and across, resist movement
How is the radial nerve tested?
Movement of wrist back and up, resist movement
Define allen’s test
Patient elevates hand and makes a fist for 20 seconds
- Firm pressure held against radial and ulnar arteries to occlude them
- Patient opens hand and should be blanched/pallor
- Examiner releases only ulnar pressure, and color should return within 5 seconds
- Repeat holding compression over the radial artery
When is Allen’s test performed?
Indications :
Used to evaluate ulnar-artery patency, collateral blood supply to hand
Performed before ABG’s, radial-artery cannulation or harvesting for CABG
What is a normal Allen’s test?
Normal Result is a negative test
Hand color returns within seconds
What is an abnl allen test?
Abnormal result is positive test
means pt does not have dual blood supply to hand
> 5 seconds is positive test
Hand remains pale until radial compression is released
Define Heberden’s Nodes
bony enlargements of the DIP joint. Classic sign of osteoarthritis.
Define Bouchard’s Nodes
bony enlargements of the PIP joint. Classic sign of osteoarthritis.
Define DIP extensor tendon avulsion
- Mallet finger:
A. Forced flexion injury
B. Pain and swelling C. DIP joint
D. Loss of DIP extension
X-ray- checking for bony avulsion fx
Stack or Linx Splint
Define Flexor Digitorum Superficialis Test
Flex finger at PIP
The only functioning tendon at the PIP
Define Flexor Digitorum Profundus Test
Flex at DIP
What does the inability to flex a finger indicate?
tendon cut or denervated
defien flexor tendon or Jersey finger injury
- Avulsion injury from rapid passive extension of the clenched fist
- Loss of flexion at PIP and/or DIP
“+” sublimus or profundus tests
define boutonniere deformity
Flexion deformity of the PIP joint
Due to interruption of the central slip of the extensor tendon
What is boutonniere injury caused by?
Injury
Inflammatory condition
Often seen w/ RA
How is boutonnierre injury treated?
Conservative –
Splint
Surgical –
Best if treated early (before 3 weeks)
Defien swan neck deformity
Hyperextension of PIPJ and flexion of DIPJ
What is swan neck injury caused by?
Most common causes of a swan neck deformity
untreated mallet finger
rheumatoid arthritis
How is swan neck injury treated?
Conservative –
Splint
Surgical –
Best if treated early (before 3 weeks)
Define ganglion cyst
Gelatinous-like fluid cyst arises from synovial sheath in joint
Women>men
Dull ache
Volar or Dorsal aspect of wrist or hand
How are ganglion cysts treated?
Conservative
NSAIDs
Aspiration if bothering pt, otherwise leave be
Surgical can be difficult as pedicle of the cyst is intra-articular.
Define carpal tunnel syndrome
Entrapment of Median Nerve- transverse carpal ligament tight causing inflammed median nerve
What causes carpal tunnel syndrome?
Repetitive job- i.e. typist, machinist Arthritis Trauma (distal radius fx) Pregnancy Thyroid disease Increased risk in DM Mostly idiopathic cause
Who is at greater risk of carpal tunnel syndrome?
Female > Male
Increased incidence during pregnancy
What are the sxs of carpal tunnel?
Pain (nocturnal) Numbness/Tingling Can be positional Clumsiness wasting of thenar eminence numbness weakness Tinel’s sign Phalen’s sign Abnl two-point discrimination Nl is 2-5 mm >5mm suggests neuropathy
What is tinel’s sign?
Efficacy
Test Sensitivity: 44-70%
Test Specificity: 94%
Technique
Percuss Median Nerve at carpal tunnel in wrist
Tap over volar carpal ligament
Interpretation:
Positive Test for Median Neuropathy Reproduces pain and tingling along Median Nerve course
What is phalen’s maneuver/test?
Efficacy
Test Sensitivity: 70 to 80%
Test Specificity: 80%
Technique
One minute acute wrist flexion against resistance
Inverse praying position place each hand dorsum against each other
Interpretation:
Positive test suggests Median Neuropathy Wrist flexion reproduces carpal tunnel symptoms Most specific if symptoms occur by 30 seconds
What is a positive phalen test?
Positive test is paresthesias
or dysesthesia in median
nerve distribution
What tests are used to dx carpal tunnel syndrome?
- Electrodiagnostic Studies
A. NCS
B. EMG
What is the non operative tx for carpal tunnel syndrome?
splint ( cock up ) or night splint
steroid injection
NSAID’s
What is the operative tx for carpal tunnel syndrome?
surgical release
arthroscopic vs. open
Define DeQuervain’s Tenosynovitis
Inflammation of EXT Pollicis Brevis and ABD Pollicis Longus tendons
What are the sxs of DeQuervain’s Tenosynovitis
Tenderness -1st Dorsal Compartment
What is the finkelstein’s test used for? How is it performed?
- DeQuervain’s Tenosynovitis
Examiner braces wrist in ulnar deviation
Examiner passively flexes thumb across palm
Alternative – Ask pt to put thumb in fist and perform ulnar deviation
Interpretation
Dorsal thumb pain suggests De Quervain’s Tenosynovitis
What are the causes of DeQuervain’s Tenosynovitis?
Over use
Injury or inflammation
What are the txt options of DeQuervain’s Tenosynovitis?
- Rest, splint
- NSAID’s, steroid injection
- Operative tenosynovectomy
What is the most commonly fractured carpal bone?
Scaphoid
70-80% of all carpal bone injuries
8% of all sports related fractures
1 in 100 college football players
Most susceptible to injury
Bridges proximal and distal rows of the carpal bones
Load to the dorsiflexed wrist as in fall onto outstretched hand
What are the sxs of scaphoid fracture?
- Painful, swollen wrist after a fall
- Tenderness in snuffbox
- High frequency of nonunion and avascular necrosis
- Initial x-rays often unremarkable
Define trigger fingers
Narrowing and inflammation of tendon
What is the cause of trigger fingers?
Repetitive gripping , DM, DJD, idiopathic
What demopgraphic iare trigger fingers more common in?
Women>men
Dominant hand
What fingers are trigger fingers most common in?
Thumb, middle and ring fingers most common
What are the sxs of trigger fingers?
Finger stiffness
Popping, clicking
Finger locked in flexed position
What are the txs of trigger fingers?
non operative ( 95% improve )
steroid injection
NSAID’s
operative
release of A1 pulley
define duputren’s contracture
Knots of tissue that form thick cords
What causes duputren’s contracture
FH, Tobacco and ETOH, DM
M>W (increase frequency in Men of Northern European descent)
What are the sxs of duputren’s contracture?
Thickening of skin, lump of tissue
Flexion contracture of the ring and small fingers
What are the txs of duputren’s contracture?
Surgery if:
rapidly progressive contracture
inconvenience
fasciotomy
fasciectomy
amputation
What are the sxs of boxer’s fx?
Pain, swelling Misalignment? Knuckle depressed Rotation Cut
Define boxer’s fracture
trauma to 5th metacarpal
Which phalanx fracture is the most disabling?
Proximal, middle or distal
Proximal most disabling
What are the sxs of phalanx fractures?
Pain,swelling
Angulation
Rotation
What is the txt for phalanx fractures?
Splint and refer to Ortho
Define skier’s thumb or gamekeeper’s thumb
Ulnar Collateral Ligament rupture of the thumb MCP joint
What are the sxs of skier’s thumb?
Instability, weak and ineffective pinch
Radially directed stress at MCP joint-stable if opens <35 degrees
What radiologic studies are indicated with and/wrist injuries?
AP and Lateral of hand and wrist
Consider Obliques and special views if fracture suspected but not seen on AP and Lateral
Why are related areas important in and/wrist injuries?
Referred pain can be due to: Herniated cervical discs Osteoarthritis Brachial plexus outlet syndrome Elbow and shoulder entrapment syndrome
What are some common causes of dorsal hand pain?
Ganglion (#1 cause of dorsal pain) Extensor tendonitis (overuse) Kienbach’s Disease
What are some common causes of volar hand pain?
Ganglion
Flexor tendinitis
Carpal tunnel syndrome
Thumb CMC joint arthritis
What are some common causes of radial hand pain?
Thumb CMC DJD
DeQuervain’s tendinitis
Scaphoid fracture
What are some common causes of ulnar hand pain?
EXT carpi ulnaris tendinitis
Synovitis
Triangular fibrocartilage complex tear
