practical wrist hand

Question 1

Radiocarpal Joints:

Resting

Closed Packed

Capsular Pattern

Answer 1

1. Zero Starting Position: longitudinal axes through the radius and the 3rd metacarpal are in a straight line
2. Resting Position: longitudinal axes through the radius and the 3rd metacapral are straight but with a little ulnar flexion
3. Closed Packed Position: Full Extension
4. Capsular Pattern: restricted equally in all directions
   a. Note that the Radiocarpal and midcarpal joints work together

Question 2

Midcarpal Joints:

Resting

Closed Packed

Capsular Pattern

Answer 2

1. Resting Position: neutral or slight flexion with (slight?) ulnar deviation
2. Closed packed position: extension with ulnar deviation
3. Capsular Pattern: equal limitation of flexion and extension
   a. Note that the Radiocarpal and midcarpal joints work together

Question 3

Radiocarpal Joint: Distraction:

Answer 3

Patient Position: seated with forearm pronated, wrist in resting position (neutral with a little ulnar and a little flexion)

Resting position: longitudinal axes through the radius and the 3rd metacapral are straight but with a little ulnar flexion

Stabilize: stabilize forearm just proximal to wrist (on table) [on radius and ulna as close to the joint as possible]

Mobilize: mobilizing hand just distal to wrist around proximal row of carpals (support hand) [find scaphoid and triquitrium and grasp around those two areas to encircle scaphoid and triquitrium]

Direction: mobilizing hand moves distally [distraction]

1. My hands are close together as possible
2. The glide is not so large

Question 4

Radiocarpal Joint: Volar (Palmar) Glide:

Answer 4

2. precede with a piccolo distraction

Patient Position: seated, forearm pronated, wrist in resting position just over the edge of the table (neutral with a little ulnar and a little flexion)

1. Note that it can also be done on the wedge with the crease of wedge at crease of joint
2. I stand above patient to allow it to go down to the floor
3. Resting position: longitudinal axes through the radius and the 3rd metacapral are straight but with a little ulnar flexion

Stabilize: forearm just proximal to wrist

Mobilize: mobilizing hand just distal to wrist around carpal bones (support hand as needed)

Direction: mobilizing hand moves in a volar direction (to the floor)

Question 5

Radiocarpal Joint: Dorsal Glide:

Answer 5

precede with a piccolo distraction

Patient Position: patient is seated with forearm supinated, wrist in resting position just over the edge of the table or wedge (neutral with a little ulnar and a little flexion)
1. Resting position: longitudinal axes through the radius and the 3rd metacapral are straight but with a little ulnar flexion

Stabilize: stabilize forearm just proximal to wrist

Mobilize: mobilizing hand just distal to wrist around carpal bones

Direction: mobilizing hand moves dorsally (to the floor)

Question 6

Radiocarpal Joint: Radial Glide:

Answer 6

precede with a piccolo distraction

Patient Position: patient is seated with forearm resting on the radial aspect, wrist in resting position just over the edge of the table or wedge

1. Ie across the table
2. Their thumb is to the floor

Stabilize: stabilize forearm just proximal to wrist on the ulnar side

Mobilize: mobilizing hand just distal to wrist around the carpals (proximal row)

Direction: mobilizing hand moves in a radial direction (glide to the floor)

Rationale: for ulnar deviation

Question 7

Radiocarpal Joint: Ulnar Glide:

Answer 7

precede with a piccolo distraction

Patient Position: patient is seated with forearm resting on the ulnar aspect, wrist in resting position just over the edge of the table or wedge
1. Get the thumb out of your way

Stabilize: stabilize the forearm just proximal to wrist on radial side

Mobilize: mobilizing hand just distal to wrist around carpals

Force Direction: mobilizing hand moves in an ulnar direction (glide to the floor)

Rationale: For radial deviation

Question 8

Case Example 1: patient cannot achieve wrist flexion: 0-45 of wrist flexion. Problem is joint. Pain is not an issue.

Answer 8

Do dorsal glide. Treating in the rest position 3 and 4 or cahse the barrier in the 45 degree of flexion and doing the glide in that position.

Question 9

Case Example 2: Patient cannot bring wrist past 10 degrees of extension:

Answer 9

treat with palmar glide, chase the barrier: Start with distraction and then go on to rest position 3 and 4 or chase the barrier set into 10 degrees and do the palmar glide.

Question 10

Midcarpal Joint: Distraction:

Answer 10

a. Patient Position: patient is seated with forearm pronated, wrist in resting position
b. Stabilize: stabilize distal to wrist on proximal row of carpals
c. Mobilize: mobilizing hand over distal row of carpals (support hand as needed)
d. Force/Direction: Mobilizing hand moves distally in a distraction

Question 11

Midcarpal Joint: Dorsal Glide:

Answer 11

a. Patient Position: seated with forearm supinated, wrist in resting position with proximal row of carpals on the edge of the table or wedge
b. Stabilize: stabilize forearm distal to wrist on the proximal row of carpals
c. Mobilize: mobilizing hand over distal row of carpals
d. Force/Direction: mobilizing hand moves dorsally

Question 12

Midcarpal Joint: Volar Glide:

Answer 12

a. Patient Position: patient is seated with forearm pronated, wrist in resting position with proximal row of carpals on the edge of the table or wedge
b. Stabilize: stabilize the forearm distal to the wrist on the proximal row of carpals
c. Mobilize: mobilizing hand over distal row of carpals
d. Force/Direction: mobilizing hand moves in a volar direction

Question 13

Midcarpal Joint: Volar Glide:

Answer 13

a. Patient Position: patient is seated with forearm pronated, wrist in resting position with proximal row of carpals on the edge of the table or wedge
b. Stabilize: stabilize the forearm distal to the wrist on the proximal row of carpals
c. Mobilize: mobilizing hand over distal row of carpals
d. Force/Direction: mobilizing hand moves in a volar direction

Question 14

Tinel’s Sign:

Answer 14

gentle tap of the anterior wrist where median nerve emerges from under the flexor retinaculum towards the hand (before it goes deep)

1. Positive sign: median nerve distribution pain or paresthesia
2. For Carpal Tunnel Syndrome: do not only rely on this test
   a. moderate specificity/ sensitivity
   b. moderate validity and reliability

Question 15

Phalen’s Test:

Answer 15

mechanically compress both median nerves at the same time by bringing the dorsal aspects of the hands together with maximal wrist flexion for 1 minute. Median nerve needs time to conduct so hold for about a minute.

1. Bilateral maximal wrist flexion X 1 minute
2. Positive sign: pain or paresthesia in median nerve distribution (mobilize it, let it stretch out a bit after)

Question 16

Finklestein Test:

Answer 16

put the muscle on stretch: put thumb into hand and then wrist ulnar deviation

1. Patient grasps thumb and maintains flexion of the MCP joint
2. Add ulnar deviation of the wrist
3. Positive sign: pain along course of abductor pollicis longus or extensor pollicis brevis –if it reproduces the cardinal sign
   a. We can isolate the two tendons by doing their specific function
   b. You will probably already have a strong suspision because it is hot and painful and they don’t want to move it.

Question 17

Watson Test:

Answer 17

scaphoid-lunate instability, suspect that is going on to a small degree but you do not see the deformity. 3 parts:

1. Wrist in neutral and grab hold of scaphoid and give it a good hold to stabilize it
2. Ulnar deviate the wrist to get the lunate to pull away from the scaphoid
3. If you hear a click or pop or reproduction of the pain is a positive test
4. Treat with quick mobilization of scaphoid and lunate (this is common, it is painful at first), a glide [if this doesn’t work then refer to the doctor]
   a. scaphoid-lunate instability, pain or click or clunk in the wrist is felt when stabilizing the scaphoid with one hand and moving wrist from radial deviation to ulnar deviation as pressure is applied to the scaphoid with the thumb of the other hand

Question 18

Watson Test:

Answer 18

scaphoid-lunate instability, suspect that is going on to a small degree but you do not see the deformity. 3 parts:

1. Wrist in neutral and grab hold of scaphoid and give it a good hold to stabilize it
2. Ulnar deviate the wrist to get the lunate to pull away from the scaphoid
3. If you hear a click or pop or reproduction of the pain is a positive test
4. Treat with quick mobilization of scaphoid and lunate (this is common, it is painful at first), a glide [if this doesn’t work then refer to the doctor]
   a. scaphoid-lunate instability, pain or click or clunk in the wrist is felt when stabilizing the scaphoid with one hand and moving wrist from radial deviation to ulnar deviation as pressure is applied to the scaphoid with the thumb of the other hand

Question 19

Murphy Sign:

Answer 19

1. Patient makes a fist
2. Therapist examines dorsal aspect
3. Positive sign: third metacarpal is level with the second and fourth metacarpal and is not the highest
4. Indicates Lunate dislocation

Question 20

TFCC Load Test:

Answer 20

1. ulnar deviate the wrist (stress the complex) and axially load the wrist: push through the 5th metacarpal down to the triquitrum and ulna to region of TFCC.
2. If not positive can add stress to the tissue and do with wrist flexion/extension or pronation/supination.
3. It is a tight compartment and needs to heel so if you know what it is you shouldn’t compress and stress.
   a. The triangle sits on the bottom of the ulna in the joint line (there is a meniscal homologue near there that isn’t a meniscus but its is unrelated), the apex point to ulnar styloid, it comes off the capsule that surrounds the radial ulnar joint so mostly on radius and base on radius and it goes over to the inside of the ulnar styloid
4. Positive sign: pain, crepitus, or clicking

Question 21

Supinate Lift Test:

Answer 21

for dorsal lesion of the TFCC
1. Ask the patient to attempt to lift the examination table while the palm is flat on the undersurface of the table (supinated hand under the table in attempt to lift it up)

2. Positive sign: pain or weakness

Question 22

MP joint

type

Answer 22

MP Joint: condyloid joint

a. 2 degrees of freedom
b. flexion/extension
c. abduction/adduction

Question 23

IP joint type

Answer 23

2. IP Joint: hinge joint
   a. 1 degree of freedom
   b. flexion/extension

Question 24

1st CMC joint type

Answer 24

1st CMC Joint: Saddle joint

a. 2 degrees of freedom
b. flexion/extension: concave on convex saddle
c. abduction/adduction: convex on concave saddle
d. to improve extension: same direction: concave on convex: mobilize in the same direction
e. improve abduction: bring thumb 90 degrees from palm of the hand move top of bone in one direction and bottom of bone in opposite direction

Question 25

CMC
thumb vs fingers

rest

closed packed

capsular pattern

Answer 25

1. Resting Position:

THUMB midway between abduction and adduction and flexion and extension

FINGERS midway between flexion and extension

2. Closed Packed Position:
   THUMB: full opposition (pad of thumb face palm of hand)

FINGERS: full flexion

3. Capsular Pattern:

THUMB: abduction then extension

FINGERS: equal limitation on all directions

Question 26

Metacarpophalangeal Joints: MCP

thumb vs fingers

rest

closed packed

capsular pattern

Answer 26

1. Resting Position: slight flexion
2. Closed Packed Position:
   THUMB: full opposition

FINGERS: full flexion

3. Capsular Pattern: flexion is more limited then extension

Question 27

Interphalangeal Joints:

thumb vs fingers

rest

closed packed

capsular pattern

Answer 27

1. Resting Position: slight flexion
2. Closed Packed Position: full extension
3. Capsular Pattern: flexion more than extension

Question 28

Distraction: MCP, PIP, DIP:

Answer 28

(traction?)
a. Patient Position: Patient is seated, hand is palm down, place finger in resting position (slight flexion)

b. Stabilize: stabilize patient hand against your body or on the table. Stabilize just proximal to the joint you are evaluating. As close to the joint as possible. Short levers and to palpate the movement better.

c. Mobilize: grip the finger distal to the joint –sink into it comfortably
1. (can be on sides or on top and bottom, in case of tendon repair don’t grasp from top and bottom, if irritated collateral ligaments need to grip the top and bottom.)

d. Direction: distract

Question 29

Volar Glide: MCP, PIP, DIP:

Answer 29

start with a piccolo distraction
a. Patient Position: patient is seated, hand is palm down, place finger in resting position (can be resting on the table)

b. Stabilize: stabilize patient’s hand against your body, stabilize just proximal to the joint you are evaluating
c. Mobilize: grip the finger distal to the joint
d. Direction: start with a piccolo distraction, glide volar/palmar then back to neutral then dorsal then back to neutral

Question 30

Dorsal Glide:

Answer 30

MCP, PIP, DIP: start with a piccolo distraction
a. Patient Position: patient is seated, hand is palm down, place finger in resting position

b. Stabilize: stabilize patient’s hand against your body, stabilize just proximal to the joint you are evaluating
c. Mobilize: grip the finger
d. Direction: start with a piccolo distraction, glide dorsal then back to neutral then volar then back to neutral

Question 31

Radial Glide: MCP, PIP, DIP:

Answer 31

start with a piccolo distraction
a. Patient Position: patient is seated, patient palm faces the PT, finger in the resting position

b. Stabilize: stabilize the patients hand against your body or on table, stabilize just proximal to the joint you are evaluating
c. Mobilize: grip the finger distal to the joint
d. Direction: start with a piccolo distraction: radial glide, then back to neutral, then ulnar glide, then back to neutral
e. Rationale: At MCP important for ab/adduction, at the other joints it is to help stretch the collateral ligaments if they are bound down

Question 32

Ulnar Glide: MCP, PIP, DIP:

Answer 32

start with a piccolo distraction
a. Patient Position: patient is seated, patient palm faces the PT, finger in the resting position

b. Stabilize: stabilize the patients hand against your body or on table, stabilize just proximal to the joint you are evaluating
c. Mobilize: grip the finger distal to the joint
d. Direction: start with a piccolo distraction: ulnar glide, then back to neutral, then radial glide, then back to neutral
e. Rationale: At MCP important for ab/adduction, at the other joints it is to help stretch the collateral ligaments if they are bound down

Question 33

Volar = Palmar Glide: 1st CMC Joint:

Answer 33

start with a piccolo distraction

a. Patient Position: patient seated, palm of hand on the table, thumb in resting position
1. Thumb resting position midway between flexion, extension, abduction and adduction
b. Stabilize: stabilize the trapezium but also the trapezoid
c. Mobilize: grasp metacarpal just distal to the joint space
d. Direction: glide in a volar or dorsal direction
e. Rationale: adduction (opposite direction, convex on concave)

Question 34

Dorsal Glide: 1st CMC Joint:

Answer 34

start with a piccolo distraction

a. Patient Position: patient seated, palm of hand on the table, thumb in resting position,
1. Thumb resting position midway between flexion, extension, abduction and adduction
b. Stabilize: stabilize the trapezium but also the trapezoid
c. Mobilize: grasp metacarpal just distal to the joint space
d. Direction: glide in a volar or dorsal direction
e. Rationale: abduction (opposite direction, convex on concave)

Question 35

Radial Glide: 1st CMC Joint:

Answer 35

start with a piccolo distraction

a. Patient Position: patient seated, ulnar border of hand on the table, thumb in resting position,
1. Can have the hand palm up with ulnar aspect against my belly
2. Thumb resting position midway between flexion, extension, abduction and adduction
b. Stabilize: stabilize the trapezium but also the trapezoid
c. Mobilize: grasp metacarpal just distal to the joint space
d. Direction: glide in a radial direction
e. Rationale: extension (same direction, concave on convex)

Question 36

Ulnar Glide: 1st CMC Joint:

Answer 36

start with a piccolo distraction

a. Patient Position: patient seated, ulnar border of hand on the table, thumb in resting position,
1. Can have the hand palm up with ulnar aspect against my belly
2. Thumb resting position midway between flexion, extension, abduction and adduction
b. Stabilize: stabilize the trapezium but also the trapezoid
c. Mobilize: grasp metacarpal just distal to the joint space
d. Direction: glide in an ulnar direction
e. Rationale: flexion (same direction, concave on convex)

Question 37

Metacarpals: arch: c

Answer 37

convex on concave: intermetacarpal joints: General Hypomobility

1. Patient’s hand rests on the table
2. Grasp the palmar surface with fingers and thumbs on dorsal surface and push in palmar direction to flatten the arch or else take thumbs and move to sides and push with fingers underneath to exaggerate the arch
3. Spread metacarpals to reverse arch

Question 38

Metacarpals: Volar/Dorsal:

Answer 38

More specific

1. Patients hand rests on the table
2. Hold the metacarpal with your thumb and index finger along the length of the bone
3. Mobilize the metacarpals around the 3rd metacarpal which is always held stable
4. Move from one metacarpal to the next and do a dorsal glide, back to neutral, palmar glide and back to neutral.
5. My thumb is along the metacarpal and my fingers are dancing on the bone in order to stabilize on the palmar aspect/can be facing the subject or next to

Question 39

Metacarpals: Volar/Dorsal:

Answer 39

More specific

1. Patients hand rests on the table
2. Hold the metacarpal with your thumb and index finger along the length of the bone
3. Mobilize the metacarpals around the 3rd metacarpal which is always held stable
4. Move from one metacarpal to the next and do a dorsal glide, back to neutral, palmar glide and back to neutral.
5. My thumb is along the metacarpal and my fingers are dancing on the bone in order to stabilize on the palmar aspect/can be facing the subject or next to

Question 40

Movement around the Capitate:

Answer 40

a. slide down metacarpal to fall onto capitate
1. Face the patient or be side to side to the patient
2. Stabilize the capitate
3. Mobilize: trapezeii, scaphoid, lunate, hamate
4. dorsal back to neutral, palmar and back to neutral

Question 41

Mobilize

Radial Side of Hand:

Answer 41

find the scaphoid on the radial side with ulnar deviation

1. Face the patient or be side to side to the patient
2. Stabilize: Get on dorsal and volar aspects of scaphoid
3. May want to stabilize ulnar aspect of hand, have the hand in slight flexion (not in the ulnar deviation used to find the scaphoid)
4. Mobilize: Move off base of metacarpal to get trapezeii: stabilize scaphoid and mobilize the 2 trapezeii
5. Move the trapezeii on the scaphoid: dorsal to neutral, palmar to neutral

Question 42

Mobilize

Ulnar Side of Hand:

Answer 42

1. Stabilize triquitrium and mobilize hamate
   a. Mobilize triquitirum into dorsal and palmar
2. Stabilize triquitrium and mobilize pisiform
   a. Mobilize the pisiform in radial and ulnar with a small pincer grip

Question 43

Mobilize

Hamate on Lunate

Answer 43

d. (Hamate on lunate:
1. Find capitate and go proximal and it pops when flex wrist
2. Hamate under 4 and 5 metacarpal
3. Mobilize hamate in dorsal and palmar direction )

Question 44

Wartenberg sign:

Answer 44

a. For ulnar neuropathy: starting position with fingers abducted, palm down on the table. Ask patient to abduct fingers. (+): cannot abduct the 5th digit
b. If you think it is ulnar neuropathy: palm flat on table and fingers abducted ask patient to adduct to get the interossei to work in the adduction
c. Concentrating on 5th
d. Ulnar neuropathy: cannot do this

e. Patient may substitute by extending the finger and dropping it down but we want them to do adduction
f. Observation:
g. atrophy of hypothenar eminance
h. Note: sensation loss to part of 4th and 5th
i. MMT failed: interossei, digiti minimi, lumbricals

Question 45

Wartenberg sign:

Answer 45

a. For ulnar neuropathy: starting position with fingers abducted, palm down on the table. Ask patient to abduct fingers. (+): cannot abduct the 5th digit
b. If you think it is ulnar neuropathy: palm flat on table and fingers abducted ask patient to adduct to get the interossei to work in the adduction
c. Concentrating on 5th
d. Ulnar neuropathy: cannot do this

e. Patient may substitute by extending the finger and dropping it down but we want them to do adduction
f. Observation:
g. atrophy of hypothenar eminance
h. Note: sensation loss to part of 4th and 5th
i. MMT failed: interossei, digiti minimi, lumbricals

Question 46

Tightness ED, Interossei, Lumbrical

Answer 46

a. Test Extensor Digitorum Tightness: (swelling usually dorsum because that is where there is space)
1. Step 1: Passively flex MCP
2. Step 2: Passively flex PIP: pain (+) because putting it on total stretch (crosses both volarly)

3. Step 3: Then passively extend at MP to put slack on the ED tendon and retry flex PIP
4. If flex PIP all the way (+)
5. If they still can’t flex PIP (-)

b. Test Intrinsic Tightness = interossei
1. Extend at MCP to put intrinsics on stretch, and flex at the PIP and DIP (claw)
2. If cannot then tight intrinsics

c. Test Lumbrical Tightness: as make a fist:
1. Tight Interossei: Lumbrical tendon is attached to the FDP, so once you flex at MCP, FDP helps and pulls and changes orientation of lumbrical tendon. If you are tight it is interossei.

2. Tight Lumbricals: MCP at 45 tightness
3. Tight ED if MCP all the way down into flexion
   d. Interossi are between the metacarpals and are our hand pumpers so if pt has edema have them do open and close abduction and adduction