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Advanced Physical Dx > Hand and Wrist Exam > Flashcards

Hand and Wrist Exam Flashcards

1
Q

What important question needs to be asked when presented with an arm/hand injury?

A

Dominate hand

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2
Q

What are the four (five?) principle mechanisms of injury?

A 
Throwing
Weight bearing
Twisting
Impact
High energy vs low energy injury
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3
Q

What are common symptoms?

A

Pain in the wrist or hand
Numbness or tingling (paresthesia) in the wrist or fingers
Loss of movement and stiffness
Deformities

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4
Q

What are the components of the PE?

A 
Inspection
Palpation
Range of Motion
Neurologic Exam
Special Tests
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5
Q

What are the components of inspection?

A
  1. Observe upper extremity as patient enters room
  2. Examine hand in function
  3. Deformities
  4. Attitude of the hand: how the hand/arm is being held
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6
Q

How is the dorsal hand and wrist inspected?

A
  1. Hills and Valleys
  2. Height of metacarpal heads
  3. Finger nails
    A. Pale or white=anemia or circulatory
    B. Spoon shaped=fungal infection
    C. Clubbed=respiratory or congenital heart
  4. Deformities
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7
Q

How is the palmar hand and wrist inspected?

A
  1. Creases
  2. Thenar and Hypothenar Eminence
  3. Hills and Valleys
  4. Web Spaces
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8
Q

What is the cascade sign?

A

Assure all fingers point to scaphoid area when flexed at PIPs
Document as no rotational abnormalities

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9
Q

How is the motor function of the hand assessed?

A
  1. Grasp/grip strength

2. Pinch strength

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10
Q

How is the sensory function of the hand assessed?

A
  1. Stereognosis (size, shape)
  2. Pinprick test
  3. Light touch test
  4. Two-point discrimination
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11
Q

What is included in rapid assessment of hand function?

A
  1. Space and stability
  2. Open and close
    - Flex digits
    - Extend digits
    - Adduct, Abduct
  3. Pinch, opposition, sensation of digits
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12
Q

Test the ROM of which tendons?

A

Flexor Digitorum Superficialis (FDS)
Extend all other digits to isolate
Test flexion of each finger then test FDP
Flexor Digitorum Profundus (FDP)

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13
Q

True false: elbow and wrist equallt participate in pronation ad supination

A

True

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14
Q

How is finger ROM tested?

A

Finger flexion
Should be able to touch finger pad to palm
Finger extension

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15
Q

How is wrist ROM tested?

A 
Radial Deviation –
toward the radius
 Ulnar Deviation –  
toward the ulna
Flexion
Extension
Supination
Pronation
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16
Q

What nerves innervate the hand?

A

Ulnar
Median
Radial
LOOK AT PICTURES

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17
Q

Which finger is innervated by C6?

A

Thumb and forefinger

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18
Q

Which finger is innervated by C7?

A

Middle finger

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19
Q

Which finger is innervated by C8?

A

Ring and pinkie finger

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20
Q

What functions are associated with each Cervical nerve?

A 
Wrist Ext – C6
Wrist Flex – C7
Finger Ext – C7
Finger Flex – C8
Finger Abd – T1
Finger Add – T1
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21
Q

What three “hooks’ of the wrist bones are palpable?

A
  1. pisiform: ulnar side
  2. Hook of hamate: easy to feel on dorsal)
  3. Scaphoid tubercle (under thumb)
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22
Q

What landmarks need to be palpated on the wrist?

A
  1. Radial Styloid
  2. Scaphoid
  3. 1st MC/Trapezium jt
  4. Lunate
  5. Lister’s Tubercle
  6. Ulnar Styloid
  7. Triquetrum
  8. TFCC
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23
Q

Define Thumb CMC joint arthritis tests

A
  1. Painful pinch or grasp
  2. “Grind Test”
    Axial pressure to thumb while palpating CMC joint
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24
Q

How is the lunate bone in the wrist palpated?

A

Flexion of the wrist facilitates palpation of the lunate

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25
Q

Define Kienbock’s disease

A
  1. Idiopathic osteonecrosis of lunate
  2. Stress or compression fracture of the lunate
    A. Disruption of blood supply with collapse and secondary fragmentation
  3. Pain and stiffness of the wrist in the ABSENCE of TRAUMA
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26
Q

Define Scaholunate dissociation

A
  1. Diagnosis often missed
  2. Pain, swelling, and decreased ROM
  3. Pressure over scaphoid tuberosity elicits pain
  4. Greatest pain over dorsal scapholunate area, accentuated with dorsiflexion
  5. X-ray shows widening of scapholunate joint space by at least 3 mm
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27
Q

Define TFCC Triangular fibrocartilage complex injuries

A
  1. Thickened pad of connective tissue that is the major ligamentous stabilizer of the distal radioulnar joint and the ulnar-carpus joint
  2. Injury from compression between lunate and head of ulna
    A. Breaking fall with hand
    B. Rotational forces-racket and throwing sports
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28
Q

What are the sxs of TFCC injury?

A
  1. Ulnar sided wrist pain, swelling, loss of grip strength
  2. “Click” with ulnar deviation
  3. Point tenderness distal to ulnar styloid
  4. TFCC load test 
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29
Q

What are the neuro muscle testings of the wrist and figners?

A

WRIST:
EXT C6
FLEX C7

FINGERS:
EXT C7
FLEX C8
ABD T1
ADD T1
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30
Q

How is the ulnar nerve tested?

A

little finger movement and resistance to movement

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31
Q

How is the median nerve tested?

A

Thumb: move up, down and across, resist movement

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32
Q

How is the radial nerve tested?

A

Movement of wrist back and up, resist movement

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33
Q

Define allen’s test

A

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
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34
Q

When is Allen’s test performed?

A

Indications :
Used to evaluate ulnar-artery patency, collateral blood supply to hand
Performed before ABG’s, radial-artery cannulation or harvesting for CABG

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35
Q

What is a normal Allen’s test?

A

Normal Result is a negative test

Hand color returns within seconds

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36
Q

What is an abnl allen test?

A

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

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37
Q

Define Heberden’s Nodes

A

bony enlargements of the DIP joint. Classic sign of osteoarthritis.

38
Q

Define Bouchard’s Nodes

A

bony enlargements of the PIP joint. Classic sign of osteoarthritis.

39
Q

Define DIP extensor tendon avulsion

A
  1. 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

40
Q

Define Flexor Digitorum Superficialis Test

A

Flex finger at PIP

The only functioning tendon at the PIP

41
Q

Define Flexor Digitorum Profundus Test

A

Flex at DIP

42
Q

What does the inability to flex a finger indicate?

A

tendon cut or denervated

43
Q

defien flexor tendon or Jersey finger injury

A
  1. Avulsion injury from rapid passive extension of the clenched fist
  2. Loss of flexion at PIP and/or DIP
    “+” sublimus or profundus tests
44
Q

define boutonniere deformity

A

Flexion deformity of the PIP joint

Due to interruption of the central slip of the extensor tendon

45
Q

What is boutonniere injury caused by?

A

Injury
Inflammatory condition
Often seen w/ RA

46
Q

How is boutonnierre injury treated?

A

Conservative –
Splint
Surgical –
Best if treated early (before 3 weeks)

47
Q

Defien swan neck deformity

A

Hyperextension of PIPJ and flexion of DIPJ

48
Q

What is swan neck injury caused by?

A

Most common causes of a swan neck deformity
untreated mallet finger
rheumatoid arthritis

49
Q

How is swan neck injury treated?

A

Conservative –
Splint
Surgical –
Best if treated early (before 3 weeks)

50
Q

Define ganglion cyst

A

Gelatinous-like fluid cyst arises from synovial sheath in joint
Women>men
Dull ache
Volar or Dorsal aspect of wrist or hand

51
Q

How are ganglion cysts treated?

A

Conservative
NSAIDs
Aspiration if bothering pt, otherwise leave be

Surgical can be difficult as pedicle of the cyst is intra-articular.

52
Q

Define carpal tunnel syndrome

A

Entrapment of Median Nerve- transverse carpal ligament tight causing inflammed median nerve

53
Q

What causes carpal tunnel syndrome?

A 
Repetitive job- i.e. typist, machinist
Arthritis
Trauma (distal radius fx)
Pregnancy
Thyroid disease
Increased risk in DM
Mostly idiopathic cause
54
Q

Who is at greater risk of carpal tunnel syndrome?

A

Female > Male

Increased incidence during pregnancy

55
Q

What are the sxs of carpal tunnel?

A 
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
56
Q

What is tinel’s sign?

A

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
57
Q

What is phalen’s maneuver/test?

A

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
58
Q

What is a positive phalen test?

A

Positive test is paresthesias
or dysesthesia in median
nerve distribution

59
Q

What tests are used to dx carpal tunnel syndrome?

A
  1. Electrodiagnostic Studies
    A. NCS
    B. EMG
60
Q

What is the non operative tx for carpal tunnel syndrome?

A

splint ( cock up ) or night splint
steroid injection
NSAID’s

61
Q

What is the operative tx for carpal tunnel syndrome?

A

surgical release

arthroscopic vs. open

62
Q

Define DeQuervain’s Tenosynovitis

A

Inflammation of EXT Pollicis Brevis and ABD Pollicis Longus tendons

63
Q

What are the sxs of DeQuervain’s Tenosynovitis

A

Tenderness -1st Dorsal Compartment

64
Q

What is the finkelstein’s test used for? How is it performed?

A
  1. 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

65
Q

What are the causes of DeQuervain’s Tenosynovitis?

A

Over use

Injury or inflammation

66
Q

What are the txt options of DeQuervain’s Tenosynovitis?

A
  1. Rest, splint
  2. NSAID’s, steroid injection
  3. Operative tenosynovectomy
67
Q

What is the most commonly fractured carpal bone?

A

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

68
Q

What are the sxs of scaphoid fracture?

A
  1. Painful, swollen wrist after a fall
  2. Tenderness in snuffbox
  3. High frequency of nonunion and avascular necrosis
  4. Initial x-rays often unremarkable
69
Q

Define trigger fingers

A

Narrowing and inflammation of tendon

70
Q

What is the cause of trigger fingers?

A

Repetitive gripping , DM, DJD, idiopathic

71
Q

What demopgraphic iare trigger fingers more common in?

A

Women>men

Dominant hand

72
Q

What fingers are trigger fingers most common in?

A

Thumb, middle and ring fingers most common

73
Q

What are the sxs of trigger fingers?

A

Finger stiffness
Popping, clicking
Finger locked in flexed position

74
Q

What are the txs of trigger fingers?

A

non operative ( 95% improve )
steroid injection
NSAID’s

operative
release of A1 pulley

75
Q

define duputren’s contracture

A

Knots of tissue that form thick cords

76
Q

What causes duputren’s contracture

A

FH, Tobacco and ETOH, DM

M>W (increase frequency in Men of Northern European descent)

77
Q

What are the sxs of duputren’s contracture?

A

Thickening of skin, lump of tissue

Flexion contracture of the ring and small fingers

78
Q

What are the txs of duputren’s contracture?

A

Surgery if:
rapidly progressive contracture
inconvenience

fasciotomy
fasciectomy
amputation

79
Q

What are the sxs of boxer’s fx?

A 
Pain, swelling
Misalignment?
Knuckle depressed
Rotation
Cut
80
Q

Define boxer’s fracture

A

trauma to 5th metacarpal

81
Q

Which phalanx fracture is the most disabling?

A

Proximal, middle or distal

Proximal most disabling

82
Q

What are the sxs of phalanx fractures?

A

Pain,swelling
Angulation
Rotation

83
Q

What is the txt for phalanx fractures?

A

Splint and refer to Ortho

84
Q

Define skier’s thumb or gamekeeper’s thumb

A

Ulnar Collateral Ligament rupture of the thumb MCP joint

85
Q

What are the sxs of skier’s thumb?

A

Instability, weak and ineffective pinch

Radially directed stress at MCP joint-stable if opens <35 degrees

86
Q

What radiologic studies are indicated with and/wrist injuries?

A

AP and Lateral of hand and wrist

Consider Obliques and special views if fracture suspected but not seen on AP and Lateral

87
Q

Why are related areas important in and/wrist injuries?

A 
Referred pain can be due to:
Herniated cervical discs
Osteoarthritis
Brachial plexus outlet syndrome
Elbow and shoulder entrapment syndrome
88
Q

What are some common causes of dorsal hand pain?

A 
Ganglion (#1 cause of dorsal pain)
Extensor tendonitis (overuse)
Kienbach’s Disease
89
Q

What are some common causes of volar hand pain?

A

Ganglion
Flexor tendinitis
Carpal tunnel syndrome
Thumb CMC joint arthritis

90
Q

What are some common causes of radial hand pain?

A

Thumb CMC DJD
DeQuervain’s tendinitis
Scaphoid fracture

91
Q

What are some common causes of ulnar hand pain?

A

EXT carpi ulnaris tendinitis
Synovitis
Triangular fibrocartilage complex tear

Advanced Physical Dx (9 decks)

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