L25 Physical Examination of the Wrist and Hand Flashcards
What are 4 things that assessment involves?
- Subjective history
- Physical examination
- Investigations review
- Outcome Measures
What are the 4 movements of the wrist?
What are 5 zones of the wrist?
- Radial dorsal Zone
- Central Dorsal Zone
- Ulnar Dorsal Zone
- Radial Volar Zone
- Ulnar Volar Zone
What are 12 observations when sitting at facing the patient in the inspection of the wrist?
- Relationship of wrist to body
- Oedema
- Normal tenodesis
- Skin:colour/moisture
- Spontaneity
- Nodules
- Hand posture
- Wounds
- Muscle atrophy
- Scars
- Gross deformity
- Sympathetic changes
What are 5 anatomical structures of the radial dorsal zone of the wrist?
- Radial styloid- End of radius (thumb long radius until a dip)
- Scaphoid
- 1st CMC jt
- grind test for OA
- Tendons – EPB, APL
- Finklestein’s
- Dorsal radial sensory n.
Where can you palpate the scaphoid (radial dorsal zone of wrist)?
- Palpate in snuff box
- Palpate volarly if concern
What should you observe for scaphoid (radial dorsal zone of wrist)?
Observe change from RD to UD
- More prominent in radial deviation than in ulnar deviation?
What should you observe for scaphoid (radial dorsal zone of wrist)?
Poor blood supply –> problems with healing
What does tenderness of scaphoid indicate (3) (radial dorsal zone of wrist)?
- fracture
- non-union
- SL instability
What are 4 features of thumb CMS Joint OA (radial dorsal zone of the wrist)?
- Common site for OA changes
- Observe for joint changes
- box sign, thumb adduction
- Palpate along line of MC until depression found.
- Early stages frequently tender on volar aspect
What is the thumb CMS grind test (radial dorsal zone of wrist)?
Done to test for OA
- Axial compression along the metacarpal onto the trapezium with rotation.
- React poorly to compression (load)
What are 2 soft tissues (radial dorsal zone of the wrist)?
- Observe first extensor compartment – ABL, EPB
- Dorsal Radial Sensory nerve
What are is De Quervain’s Tenosynovitis (radial dorsal zone of wrist)?
- EPB and APL tendons form first extensor compartment- palpate approximately 2cm proximal to radial styloid
- Resist EPB
- Resist APL
- Finkelstein’s test – thumb flexion and then wrist UD
What is the test for De Quervain’s Tenosynovitis?
- Test: thumb flexion with ulnar deviation = Stretched
- Pain indicates possible pathology
What are 4 features of the dorsal radial sensory nerve (dorsal radial zone of wrist)? What is the test? How is it done?
- Irritation is this area is called: Wartenburg’s syndrome/neuralgia
- Numbness tingling pain dorsal radial aspect of hand
- Susceptible to swelling and compressive force eg straps, tape, surgery
- On stretch in wrist flexion and UD further stretch
- Tinel’s – tape distally to proximally along pathway of nerve
What are 4 Radial Dorsal Zone Differential Diagnosis (most common to least common)?
- First CMC OA- Older and female
- De Quervain’s tenosynovitis
- Scaphoid fracture/non-union
- DRSN neuritis
What are 6 structures in the central dorsal zone of the wrist?
- Lister’s tubercle
- Dorsal rim radius
- Lunate
- Scapholunate Interval
- Dorsal wrist ganglion
- ECRL, ECRB tendons
What are 2 areas to palpate in the centreal dorsal zone of the wrist?
- Lister’s tubercle – useful landmark
- Dorsal rim radius – repetitive loading eg gymnasts wrist or acute fracture
What are 2 features the lunate in the central dorsal zone of the wrist?
- Find Lister’s tubercle move distally and ulnarly or alternatively palpate down the 3rd MC to the capitate to the lunate
- Lunate more prominent in wrist flexion
What does tenderness of lunate mean in the central dorsal zone of the wrist?
Tenderness maybe a rare condition – Kienbock’s, an avascular necrosis of the lunate
What is the scapholunate interval in the central dorsal zone of the wrist?
Palpate between the scaphoid and the lunate
What does tenderness of scapholunate interval mean in the central dorsal zone of the wrist?
Tenderness may indicate either scapholunate ligament injury/instability or wrist ganglion
What are 2 symptoms if the scapholunate interval/ligament is injuried in the central dorsal zone of the wrist?
If the ligament is injured then patients may describe pain and clicking in the wrist
What is the scaphoid shift test/Watson’s in the central dorsal zone of the wrist? What is a positive test?
- 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
What are 3 features of normal SL biomechanics in the central dorsal zone of the wrist?
- In a normal wrist the proximal row (Scaphoid, Lunate and Triquetrum) move as a single unit.
- 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)
- 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
What is dorsal wrist ganglion vs carpal Bos in the central dorsal zone of the wrist?
- Commonly at SL joint
- Cyst or herniation from the wrist joint
- More evident in wrist flexion
- Size not indicative of symptoms
What are 4 injuries (most common to least common) in the central dorsal zone of the wrist?
- SL ganglion
- SL ligament injury
- ECRB and RCRL tendons
- Lunate
What are 5 structures of the ulnar dorsal zone of the wrist?
- Ulnar styloid
- Ulnar Head
- DRU jt
- TFCC
- ECU tendon
What are 2 features of the ulnar head in the ulnar orsal zone of the wrist?
- observe prominence
- In pronation (more prominent) compared to in supination
- note position changes from supination to pronation
What is a feature of the ulnar styloid in the ulnar orsal zone of the wrist?
may indicate a fracture or contusion
What are 5 features of the distal radial ulnar joint in the ulnar orsal zone of the wrist?
- Palpate between the radius and ulnar
- Piano Key Test/Ballottement test – Assesses DRUJ Stability
- Stabilise the radius, provide a PA/AP glide through the distal ulnar through rotation range
- Normally no A/P P/A movement in end range pron/supination
- Pain or increased mobility may indicate instability
What are 4 features of the triangular fibrocartilage complex (TFCC) in the ulnar dorsal zone of the wrist?
- Structures between the ulnar and the carpus
- Palpate in ulnar fovea consists of articular disc, RU ligaments, Ulnocarpal ligament, ECU sheath
- Can be traumatic (eg fall with rotating forearm) or degenerative (eg repetitive UD)
What are 2 tests of the triangular fibrocartilage complex (TFCC) in the ulnar dorsal zone of the wrist?
- 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
- 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
What are 2 tests of the ECU tendinopathy in the ulnar dorsal zone of the wrist?
- Position – palpate between ulnar and 5th MC Resist wrist extension with ulnar deviation Mild swelling maybe present
- Alternative test – resist thumb abduction in neutral wrist position, creates an isometric ECU contraction with no loading of the ulnar sided structures
What are 3 features of ECU subluxation in the ulnar dorsal zone of the wrist?
- In pronation the ECU lies ulnar to the ulna head, as the wrist moves into supination the ECU moves dorsally
- The ECU can be unstable and the pain and clicking of the tendon can occur through rotation
- Test – resist in ECU in pronation, ask the patient to supinate while maintaining ECU resistance
What are 4 injuries in the ulnar dorsal zone of the wrist?
- ulnar styloid fracture/nonunion
- DRU jt instability
- TFCC injury
- ECU tendinitis, subluxation
What are 3 structures in the radial volar zone of the wrist?
- Scaphoid tubercle
- FCR tendon
- Median nerve
Where is the scaphoid tubercle in the radial volar zone of the wrist? What does tenderness mean?
base of the thenar crease, move the wrist from RD to UD.
Tenderness indicates scaphoid disease
Where is the FCR tendon in the radial volar zone of the wrist? What does tenderness mean?
just ulnar to the scaphoid tuberosity, site of tendonitis, pain with wrist flexion and RD
FCR VS FCU. Which one is stronger in flexion?
FCU
ECRL/ECRB VS ECU. Which one is stronger in extension?
ECRL/ECRB
What are 4 tests for carpal tunnel syndrome (median nerve) for the radial volar zone of the wrist?
- Phalen’s
- Durkan/Carpal Compression Test
- Wrist Flexion & Carpal Compression
- Tinel
What is the Phalen’s test for carpal tunnel syndrome (median nerve) for the radial volar zone of the wrist?
sustained wrist flexion for 30- 60 seconds
Postive test: Pins and needles and numbness, or pain
What is the Durkan’s test for carpal tunnel syndrome (median nerve) for the radial volar zone of the wrist?
compression test 30 seconds
Postive test: Pins and needles and numbness, or pain
What is the most sensitive test for carpal tunnel syndrome (median nerve) for the radial volar zone of the wrist?
Combined Phalen’s and Durkan’s
What are 3 injuries for the radial volar zone of the wrist?
- Scaphoid problems
- FCR tendonitis
- Carpal tunnel syndrome
What are 3 structures of the ulnar volar zone of the wrist?
- Pisiform
- Hook of Hamate
- FCU
What is the pisiform of the ulnar volar zone of the wrist?
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
What is a FCU tendon injury of the ulnar volar zone of the wrist?
- palpate
- resist wrist flexion with ulnar deviation
- pain may indicate tendon changes
What are 3 features of the hook of hamate of the ulnar volar zone of the wrist?
- hook portion of the hamate can break in sports such as golf, baseball and hockey
- palpate 2cm distal and centrally from the pisiform
- tenderness may indicate a fracture
What are 3 injuries of the ulnar volar zone of the wrist?
- FCU
- Pisiform
- Hook of hamate
How can you diagnosis hand intrinsic tightness?
