Hand and wrist examination

Question 1

What are the initial steps in examining the hands, fingers, and wrist?

Answer 1

1) Insepect: swelling, redness, atrophy

2) Palpation: Tenderness and warmth

3) Movement: Range of motion, flexion and extension

• always compare with the opposite side

Question 2

What are the patient’s demographics?

Answer 2

1) Name

2) Age

3) Gender

4) Occupation

5) Hand dominance

Question 3

When is a scaphoid fracture seen on X-rays?

Answer 3

After 10 days as the callus forms

Question 4

What does a history of a fall on an outstretched hand indicate?

Answer 4

It might indicate an affected:

1) Metacarpal
2) Scaphoid
3) Distal radius
4) Elbow
5) Clavicle
6) Shoulder dislocation

Question 5

What is the clinical importance of a scaphoid fracture?

Answer 5

A scaphoid fracture can cause necrosis as the blood supply of the hand comes from distal to proximal

Question 6

A fracture of the distal radius will cause what type of deformity?

Answer 6

Dinner fork deformity

Question 7

What are the red flags regarding the past medical history when examining the hand and the wrist?

Answer 7

1) Diabetes

2) Cardiac, pulmonary, or renal disease

3) Rheumatologc and dermatologic problems

4) Surgical history

Question 8

What are the important things regarding the social history when examining the wrist and hand of a patient?

Answer 8

1) Tobacco use (as it can affect the healing process)

2) Sport and activities involved in (can be a reason for the complaint)

Question 9

How to physically examine the wrist and hand

Answer 9

1) Inspect (discoloration, deformity, atrophy, wounds, and scars)

2) Palpate (

3) Move

4) Neurologic/vascular examination

5) Special tests

Question 10

What are the different dicolorations of the hand?

Answer 10

1) Redness: cellulitis

2) White: Arterial block

3) Blue/purple: venous congestion

4) Patches of blue/purple: Trauma

5) Block spots/lines: you must rule out melanoma

6) Other colors might be due to fungi, viruses, or psoriasis

7) You should also look for creases which could disappear with swelling, thenar (flat in case of chronic medial neuropathy) and hypothenar eminence, hills and valleys and carpel tunnel syndrome

8) Ganlgions: which are cystic structure that arises from the synovial sheath

Question 11

What is the cascade sign?

Answer 11

When examining the hand and the fingers, if there was any fracture the fingers won’t point towards the scaphoid when flexed at the proximal interphalangeal joint

Question 12

How to assess the range of motion of the hand and wrist?

Answer 12

1) Active motion: Where the patient’s own muscles work and you should identify tendon continuity, nerve function, & muscle strength

2) Passive: you move the patient’s hand

• Note if the movement is accompanied by pain, associated with instability or crepitus

Question 13

What are the different movements done to examine the hand and the wrist?

Answer 13

1) Forearm pronation

2) Forearm supination

3) Wrist flexion (palmar flexion “90 degrees”)

4) Wrist extension (dorsal flexion “90 degrees”)

5) Wrist radial deviation (30 degrees)

6) Wrist ulnar deviation (20 degrees)

• For the fingers, including thumb:
  1) Flexion
  2) Extension
  3) Abduction
  4) Adduction
  5) Opposition

Question 14

What are the different ROM of the finger joints?

Answer 14

1) MCP JOINT:
- Flex: 90 degrees
- Extension: 20 degrees

2) PIP JOINT:
- FLEX: 90 Degrees
- Exten: 0 degrees

3) DIP JOINT:
- Flex: 80 degrees
- Exten: 0 degrees

Question 15

How to assess the muscles and tendons?

Answer 15

• Intrinsic muscles originate and insert within the hand
• Extrinsic muscles and myotendinous units span the forearm and hand when testing the patient must resist the action of a particular muscle

1) To test the flexor pollicis longus: flexion of the thumb IP joint

2) Flexor digitorum profundus: flexion of finger DIP joint while the examiner holds the PIP joint straight

3) Flexor digitorum superficialis: Flexion of the PIP joint while the examiner holds the other fingers fully extended

Question 16

What are the six dorsal extensor compartments of the wrist?

Answer 16

1) Compartment 1:
- EPB (Extensor pollicis brevis)
- APL (Abductor pollicis longus)

2) Compartment 2:
- ECRB (Extensor carpi radialis brevis)
- ECRL (extensor carpi radialis longus)

3) Compartment 3:
- EPL (Extensor pollicis longus)

4) Compartment 4:
- EDC (Extensor digitorum communis)
- EIP (Extensor indicis proprius)

5) Compartment 5:
- EDM (Extensor digiti minimi)

6) Compartment 6:
- ECU (Extensor carpi ulnaris)

• If there is high pressure inside the compartment: give the patient an injection or surgery to release the pressure

Question 17

How to examine the sensory neurons of the hand?

Answer 17

• Testing should include crude touch, Light touch, 2 point discrimination, and vibration

1) Radial Nerve (Dorsal: Thumb + 2.5 fingers without their tips, Palmar: the first part of the thumb)

2) Median Nerve (Dorsal: Tips of the thumb and 2.5 fingers, Palmar: Thumb + 2.5 fingers including their tips)

3) Ulnar Nerve (Dorsal: Last 1.5 fingers, Palmar: Last 1.5 fingers including their tips)

Question 18

What are the different vascular examinations?

Answer 18

Requires inspection and palpation skills

Arterial blockage: pale, white, or gray fingers

Venous blockage: blue or purple discoloration

Other findings: Coolness

Loss of tissue pressure (turgor)

Capillary refill (normal is < 2 seconds at nail bed)

Subungual splinter hemorrhages: emboli

Question 19

What are the special tests done for the hand and wrist?

Answer 19

1) Grind test

2) DeQuervain’s Tenosynovitis (Finkelstein test)

3) Tinel’s test

4) Phalen’s test

5) Allen’s test (vascular test)

Question 20

What is the Grind test?

Answer 20

• Used to test for carpometacarpal joint osteoarthritis (thumb pathologies)

1) The examiner will apply an axial load to the thumb, moving it from side to side

• The test is positive if there is pain, crepitus, or Instability

Question 21

Describe Finkelstein test

Answer 21

1) The patient will close his fist onto his thumb and the examiner will apply force to deviate it ulnary

• Detects Inflammation of the extensor pollicis brevis and abductor pollicis longus (tenderness in the first compartment of the wrist)

Question 22

What are the tests done to the wrist and hand to examine “carpal tunnel syndrome”

Answer 22

• Median nerve compression (carpal tunnel syndrome)

1) Tinel’s test:

Tap on the valley in the palmar surface of the hand

2) Phalen’s test:

• Place both dorsal aspects of the hand together and flex both wrists maximally

Question 23

Describe the Allen’s test (vascular test)

Answer 23

• Test both ulnar and radial artery blood flow

1) The patient makes a tight fist and the examiner manually occludes both the radial and ulnar artery

2) The examiner releases one of the vessels and examines for reperfusion in the long finger

3) Abnormal test: hand reperfusion > 5 seconds

4) The test is repeated for the other artery

Question 24

What are the signs of the hand that are caused by rheumatoid arthritis?

Answer 24

1) MCP Swelling

2) Swan neck deformity

3) Ulnar deviation at MCP joint

4) Nodules along tendon sheaths

Question 25

What are the signs in the hand for osteoarthritis?

Answer 25

1) Herbenden’s nodes: Nodules in the distal interphalangeal joint

2) Bouchard’s nodes: Nodules in the proximal interphalangeal joint