L25 Physical Examination of the Wrist and Hand

Question 1

What are 4 things that assessment involves?

Answer 1

1. Subjective history
2. Physical examination
3. Investigations review
4. Outcome Measures

Question 2

What are the 4 movements of the wrist?

Answer 2

Question 3

What are 5 zones of the wrist?

Answer 3

1. Radial dorsal Zone
2. Central Dorsal Zone
3. Ulnar Dorsal Zone
4. Radial Volar Zone
5. Ulnar Volar Zone

Question 4

What are 12 observations when sitting at facing the patient in the inspection of the wrist?

Answer 4

1. Relationship of wrist to body
2. Oedema
3. Normal tenodesis
4. Skin:colour/moisture
5. Spontaneity
6. Nodules
7. Hand posture
8. Wounds
9. Muscle atrophy
10. Scars
11. Gross deformity
12. Sympathetic changes

Question 5

What are 5 anatomical structures of the radial dorsal zone of the wrist?

Answer 5

1. Radial styloid- End of radius (thumb long radius until a dip)
2. Scaphoid
3. 1st CMC jt
   
   • grind test for OA
4. Tendons – EPB, APL
   
   • Finklestein’s
5. Dorsal radial sensory n.

Question 6

Where can you palpate the scaphoid (radial dorsal zone of wrist)?

Answer 6

• Palpate in snuff box
• Palpate volarly if concern

Question 7

What should you observe for scaphoid (radial dorsal zone of wrist)?

Answer 7

Observe change from RD to UD

• More prominent in radial deviation than in ulnar deviation?

Question 8

What should you observe for scaphoid (radial dorsal zone of wrist)?

Answer 8

Poor blood supply –> problems with healing

Question 9

What does tenderness of scaphoid indicate (3) (radial dorsal zone of wrist)?

Answer 9

1. fracture
2. non-union
3. SL instability

Question 10

What are 4 features of thumb CMS Joint OA (radial dorsal zone of the wrist)?

Answer 10

1. Common site for OA changes
2. Observe for joint changes
   
   • box sign, thumb adduction
3. Palpate along line of MC until depression found.
4. Early stages frequently tender on volar aspect

Question 11

What is the thumb CMS grind test (radial dorsal zone of wrist)?

Answer 11

Done to test for OA

• Axial compression along the metacarpal onto the trapezium with rotation.
  
  • React poorly to compression (load)

Question 12

What are 2 soft tissues (radial dorsal zone of the wrist)?

Answer 12

1. Observe first extensor compartment – ABL, EPB
2. Dorsal Radial Sensory nerve

Question 13

What are is De Quervain’s Tenosynovitis (radial dorsal zone of wrist)?

Answer 13

1. EPB and APL tendons form first extensor compartment- palpate approximately 2cm proximal to radial styloid
2. Resist EPB
3. Resist APL
4. Finkelstein’s test – thumb flexion and then wrist UD

Question 14

What is the test for De Quervain’s Tenosynovitis?

Answer 14

• Test: thumb flexion with ulnar deviation = Stretched
• Pain indicates possible pathology

Question 15

What are 4 features of the dorsal radial sensory nerve (dorsal radial zone of wrist)? What is the test? How is it done?

Answer 15

1. Irritation is this area is called: Wartenburg’s syndrome/neuralgia
2. Numbness tingling pain dorsal radial aspect of hand
3. Susceptible to swelling and compressive force eg straps, tape, surgery
4. On stretch in wrist flexion and UD further stretch

• Tinel’s – tape distally to proximally along pathway of nerve

Question 16

What are 4 Radial Dorsal Zone Differential Diagnosis (most common to least common)?

Answer 16

1. First CMC OA- Older and female
2. De Quervain’s tenosynovitis
3. Scaphoid fracture/non-union
4. DRSN neuritis

Question 17

What are 6 structures in the central dorsal zone of the wrist?

Answer 17

1. Lister’s tubercle
2. Dorsal rim radius
3. Lunate
4. Scapholunate Interval
5. Dorsal wrist ganglion
6. ECRL, ECRB tendons

Question 18

What are 2 areas to palpate in the centreal dorsal zone of the wrist?

Answer 18

1. Lister’s tubercle – useful landmark
2. Dorsal rim radius – repetitive loading eg gymnasts wrist or acute fracture

Question 19

What are 2 features the lunate in the central dorsal zone of the wrist?

Answer 19

1. Find Lister’s tubercle move distally and ulnarly or alternatively palpate down the 3rd MC to the capitate to the lunate
2. Lunate more prominent in wrist flexion

Question 20

What does tenderness of lunate mean in the central dorsal zone of the wrist?

Answer 20

Tenderness maybe a rare condition – Kienbock’s, an avascular necrosis of the lunate

Question 21

What is the scapholunate interval in the central dorsal zone of the wrist?

Answer 21

Palpate between the scaphoid and the lunate

Question 22

What does tenderness of scapholunate interval mean in the central dorsal zone of the wrist?

Answer 22

Tenderness may indicate either scapholunate ligament injury/instability or wrist ganglion

Question 23

What are 2 symptoms if the scapholunate interval/ligament is injuried in the central dorsal zone of the wrist?

Answer 23

If the ligament is injured then patients may describe pain and clicking in the wrist

Question 24

What is the scaphoid shift test/Watson’s in the central dorsal zone of the wrist? What is a positive test?

Answer 24

• Done to test the SL ligament
• Rest the patient’s elbow on the table and place the wrist in slight UD.
• Apply an upward pressure on the scaphoid tubercle volarly, index finger resting dorsally over the scaphoid
• Move from ulnar to radial deviation + slight flexion
• Gently release pressure through scaphoid tubercle at maximum RD
• Positive test – pain and clunk

Question 25

What are 3 features of normal SL biomechanics in the central dorsal zone of the wrist?

Answer 25

1. In a normal wrist the proximal row (Scaphoid, Lunate and Triquetrum) move as a single unit. 2. In ulnar deviation the scaphoid is sitting in extension (it is not prominent) as the wrist is brought into radial deviation the scaphoid will flex (and become more prominent) 3. In an abnormal wrist, the scaphoid does not have its supporting structures and when the pressure is released from the examiners thumb it clunks or Shift back into position

Question 26

What is dorsal wrist ganglion vs carpal Bos in the central dorsal zone of the wrist?

Answer 26

* Commonly at SL joint * Cyst or herniation from the wrist joint * More evident in wrist flexion * Size not indicative of symptoms

Question 27

What are 4 injuries (most common to least common) in the central dorsal zone of the wrist?

Answer 27

1. SL ganglion 2. SL ligament injury 3. ECRB and RCRL tendons 4. Lunate

Question 28

What are 5 structures of the ulnar dorsal zone of the wrist?

Answer 28

1. Ulnar styloid 2. Ulnar Head 3. DRU jt 4. TFCC 5. ECU tendon

Question 29

What are 2 features of the ulnar head in the ulnar orsal zone of the wrist?

Answer 29

1. observe prominence * In pronation (more prominent) compared to in supination 2. note position changes from supination to pronation

Question 30

What is a feature of the ulnar styloid in the ulnar orsal zone of the wrist?

Answer 30

may indicate a fracture or contusion

Question 31

What are 5 features of the distal radial ulnar joint in the ulnar orsal zone of the wrist?

Answer 31

1. Palpate between the radius and ulnar 2. Piano Key Test/Ballottement test – Assesses DRUJ Stability 3. Stabilise the radius, provide a PA/AP glide through the distal ulnar through rotation range 4. Normally no A/P P/A movement in end range pron/supination 5. Pain or increased mobility may indicate instability

Question 32

What are 4 features of the triangular fibrocartilage complex (TFCC) in the ulnar dorsal zone of the wrist?

Answer 32

1. Structures between the ulnar and the carpus 2. Palpate in ulnar fovea consists of articular disc, RU ligaments, Ulnocarpal ligament, ECU sheath 3. Can be traumatic (eg fall with rotating forearm) or degenerative (eg repetitive UD)

Question 33

What are 2 tests of the triangular fibrocartilage complex (TFCC) in the ulnar dorsal zone of the wrist?

Answer 33

1. Palpation of the ulnar fovea (attachment point for the TFCC) pressure in between the ulnar styloid and the FCU tendon, between ulnar head and pisiform. Tenderness indicate local inflammation 2. TFCC load test – for tears, ulnarly deviate the wrist and axially load, move the wrist from flexion into extension, Positive test with have pain and crepitus

Question 34

What are 2 tests of the ECU tendinopathy in the ulnar dorsal zone of the wrist?

Answer 34

1. Position – palpate between ulnar and 5th MC Resist wrist extension with ulnar deviation Mild swelling maybe present 2. Alternative test – resist thumb abduction in neutral wrist position, creates an isometric ECU contraction with no loading of the ulnar sided structures

Question 35

What are 3 features of ECU subluxation in the ulnar dorsal zone of the wrist?

Answer 35

1. In pronation the ECU lies ulnar to the ulna head, as the wrist moves into supination the ECU moves dorsally 2. The ECU can be unstable and the pain and clicking of the tendon can occur through rotation 3. Test – resist in ECU in pronation, ask the patient to supinate while maintaining ECU resistance

Question 36

What are 4 injuries in the ulnar dorsal zone of the wrist?

Answer 36

1. ulnar styloid fracture/nonunion 2. DRU jt instability 3. TFCC injury 4. ECU tendinitis, subluxation

Question 37

What are 3 structures in the radial volar zone of the wrist?

Answer 37

1. Scaphoid tubercle 2. FCR tendon 3. Median nerve

Question 38

Where is the scaphoid tubercle in the radial volar zone of the wrist? What does tenderness mean?

Answer 38

base of the thenar crease, move the wrist from RD to UD. Tenderness indicates scaphoid disease

Question 39

Where is the FCR tendon in the radial volar zone of the wrist? What does tenderness mean?

Answer 39

just ulnar to the scaphoid tuberosity, site of tendonitis, pain with wrist flexion and RD

Question 40

FCR VS FCU. Which one is stronger in flexion?

Answer 40

FCU

Question 41

ECRL/ECRB VS ECU. Which one is stronger in extension?

Answer 41

ECRL/ECRB

Question 42

What are 4 tests for carpal tunnel syndrome (median nerve) for the radial volar zone of the wrist?

Answer 42

1. Phalen’s 2. Durkan/Carpal Compression Test 3. Wrist Flexion & Carpal Compression 4. Tinel

Question 43

What is the Phalen's test for carpal tunnel syndrome (median nerve) for the radial volar zone of the wrist?

Answer 43

sustained wrist flexion for 30- 60 seconds Postive test: Pins and needles and numbness, or pain

Question 44

What is the Durkan's test for carpal tunnel syndrome (median nerve) for the radial volar zone of the wrist?

Answer 44

compression test 30 seconds Postive test: Pins and needles and numbness, or pain

Question 45

What is the most sensitive test for carpal tunnel syndrome (median nerve) for the radial volar zone of the wrist?

Answer 45

Combined Phalen's and Durkan's

Question 46

What are 3 injuries for the radial volar zone of the wrist?

Answer 46

1. Scaphoid problems 2. FCR tendonitis 3. Carpal tunnel syndrome

Question 47

What are 3 structures of the ulnar volar zone of the wrist?

Answer 47

1. Pisiform 2. Hook of Hamate 3. FCU

Question 48

What is the pisiform of the ulnar volar zone of the wrist?

Answer 48

small bone in the FCU tendon, can be a site for OA * Sesamoid bone (for FCU --\> improve mechanical function- advantage) * Piso-triquetrum OA (possible) * Most are physios

Question 49

What is a FCU tendon injury of the ulnar volar zone of the wrist?

Answer 49

1. palpate 2. resist wrist flexion with ulnar deviation 3. pain may indicate tendon changes

Question 50

What are 3 features of the hook of hamate of the ulnar volar zone of the wrist?

Answer 50

1. hook portion of the hamate can break in sports such as golf, baseball and hockey 2. palpate 2cm distal and centrally from the pisiform 3. tenderness may indicate a fracture

Question 51

What are 3 injuries of the ulnar volar zone of the wrist?

Answer 51

1. FCU 2. Pisiform 3. Hook of hamate

Question 52

How can you diagnosis hand intrinsic tightness?

Answer 52