Hand and wrist examination Flashcards
What are the initial steps in examining the hands, fingers, and wrist?
1) Insepect: swelling, redness, atrophy
2) Palpation: Tenderness and warmth
3) Movement: Range of motion, flexion and extension
- always compare with the opposite side
What are the patient’s demographics?
1) Name
2) Age
3) Gender
4) Occupation
5) Hand dominance
When is a scaphoid fracture seen on X-rays?
After 10 days as the callus forms
What does a history of a fall on an outstretched hand indicate?
It might indicate an affected:
1) Metacarpal
2) Scaphoid
3) Distal radius
4) Elbow
5) Clavicle
6) Shoulder dislocation
What is the clinical importance of a scaphoid fracture?
A scaphoid fracture can cause necrosis as the blood supply of the hand comes from distal to proximal
A fracture of the distal radius will cause what type of deformity?
Dinner fork deformity
What are the red flags regarding the past medical history when examining the hand and the wrist?
1) Diabetes
2) Cardiac, pulmonary, or renal disease
3) Rheumatologc and dermatologic problems
4) Surgical history
What are the important things regarding the social history when examining the wrist and hand of a patient?
1) Tobacco use (as it can affect the healing process)
2) Sport and activities involved in (can be a reason for the complaint)
How to physically examine the wrist and hand
1) Inspect (discoloration, deformity, atrophy, wounds, and scars)
2) Palpate (
3) Move
4) Neurologic/vascular examination
5) Special tests
What are the different dicolorations of the hand?
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
What is the cascade sign?
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
How to assess the range of motion of the hand and wrist?
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
What are the different movements done to examine the hand and the wrist?
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
What are the different ROM of the finger joints?
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
How to assess the muscles and tendons?
- 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
What are the six dorsal extensor compartments of the wrist?
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
How to examine the sensory neurons of the hand?
- 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)
What are the different vascular examinations?
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
What are the special tests done for the hand and wrist?
1) Grind test
2) DeQuervain’s Tenosynovitis (Finkelstein test)
3) Tinel’s test
4) Phalen’s test
5) Allen’s test (vascular test)
What is the Grind test?
- 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
Describe Finkelstein test
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)
What are the tests done to the wrist and hand to examine “carpal tunnel syndrome”
- 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
Describe the Allen’s test (vascular test)
- 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
What are the signs of the hand that are caused by rheumatoid arthritis?
1) MCP Swelling
2) Swan neck deformity
3) Ulnar deviation at MCP joint
4) Nodules along tendon sheaths
What are the signs in the hand for osteoarthritis?
1) Herbenden’s nodes: Nodules in the distal interphalangeal joint
2) Bouchard’s nodes: Nodules in the proximal interphalangeal joint
