Special Tests of the FWH

Question 1

Bunnel-Littler Test (Intrinsic Plus Test)

Answer 1

• Used to determine if flexion restriction at the PIP joints is due to tightness of the intrinsic muscles, or restriction at the MCP capsule
• MCP Joint held by the clinician in a few degrees of extension, Clinicians other hand attempts to flex PIP
• If the joint cannot flex, tightness of the intrinsics or a joint capsular contraction should be suspected
• From this position, clinician slightly flexes the MCP joint (relaxing intrinsics) and attempts to flex the PIP
• If the joint can now flex=intrinsics are tight
• If it can’t= restriction prob due to capsular contraction

Question 2

Haines-Zancolli Test

Answer 2

• Used to determine whether restricted flexion at the DIP joint is due to a restriction of the PIP J capsule or tightness of the oblique retinacular ligament
• Same as above, except with PIP and DIP
• Clinician positions and holds PIP joint in neutral with one hand, attempts to flex the DIP with the other
• If no flexion, it can be due to a tight retinacular ligament or capsular contraction
• PIP joint is then slightly flexed(relaxes retinacular lig)
• If can now flex= retinacular ligament tightness
• If DIP can’t= capsular contraction

Question 3

Thumb CMC Grind Test

Answer 3

• Used to assess integrity of the thumb CMC joint
• Clinician grasps the thumb metacarpal using the thumb and index finger of one hand
• With the other hand, grasp the proximal aspect of the thumb CMC joint
• Provide an axial compressive force, combined with rotation, to the thumb CMC joint
• Positive test= reproduction of the patient’s symptoms and crepitus

Question 4

Lichtman Test

Answer 4

• Provacative test for midcarpal instability
• Patient’s forearm is positioned in pronation and the hand is held relaxed and supported
• Clinician gently moves the patients hand from RD to UD while compressing the carpus into the radius
• Positive test= he midcarpal row appears to jump or snap from a palmarly subluxed positive to the height of the proximal row

Question 5

Linscheid Test

Answer 5

• Used to detect ligamentous injury and instability of the second and third CMC joints
• Clinician supports the metacarpal shafts
• Press distally over the metacarpal heads in palmar and dorsal directions
• Positive test produces pain localized to the CMC joints

Question 6

Carpal Shake Test

Answer 6

• Used to assist in diagnosis of intercarpal synovitis
• Clinician grasps the patient’s distal forearm and the patient is asked to relax
• Clinician shakes the wrist
• Positive test= pain or resistance to this test

Question 7

Press (sit to stand) Test

Answer 7

• Used to assist in diagnosis of TFCC tear
• Patient sitting with both hands on the armrests of a chair
• Patient then attempts to lift their body slightly off the chair
• Positive test= pain or resistance to this test

Question 8

Supination Lift Test

Answer 8

• Patient in sitting with elbows flexed to 90 and the forearms supinated
• Patient is asked to place the palms flat on the underside of a table or against the clinicians hands
• Patient is asked to lift the table or push up against the the resting clinicians hands
• Positive test= pain localized to the ulnar side of the wrist with difficulty appling force (TFCC tear)

Question 9

Ulnar Impaction Test

Answer 9

• Used to assess the articulating between the ulnar carpus and the TFCC
• Patient is sitting with the elbow flexed to 90, wrist positioned in UD, and fingers positioned in a slight fist
• Clinician loads the wrist via a compressive force through the 4th and 5th metacarpals
• Positive test= pain

Question 10

Finkelstein Test

Answer 10

• Used to detect tenosynovitis of the APL and EPB
• Clinician stabilizes the forearm with one hand
• Grasps the thumb and deviates the wrist to the ulnar side with the other hand
• Positive test= pain over APL and EPB tendons at the wrist
• No diagnostic accuracy studies have been performed to determine the sensitivity and specificity of this test, so the results of this test must be interpreted with caution
• Positive test may also indicated Wartenberg syndrome, Basilar Thumb Arthrosis, EPB entrapment, or Intersection Syndrome

Question 11

Radioulnar Ballotment Test

Answer 11

• Used to assess DRUJ instability
• Patient’s elbow is flexed
• Clinician uses their thumb and index finger to stabilize the radius radially and the ulnar head ulnarly
• Stress is applied in an anterior-posterior direction
• Normally there is little movement in the anterior or posterior direction in maximum supination or pronation
• Positive test= pain or mobility
• Suggests radioulnar instability

Question 12

Wartenberg Test

Answer 12

• Used with patients who complain of pain over the distal radial forearm associated with paresthesisass over the posterior radial hand (Wartenberg Syndrome)
• Wartenberg test involves tapping the index finger over the superficial radial nerve on the posterior and radial side of the wrist
• Positive test= indicated by local tenderness and paresthesia with this maneuver

Question 13

Finger Extension Test

Answer 13

• Used to demonstrate posterior wrist syndrome (localized scapholunate synovitis)
• Clinician instructs the patient to fully blex the wrist and then actively extend the digits at both the IP and MCP joints
• Clinician then applies pressure on the fingers into flexion at the MCP joints while the patient continues to actively extend
• Positive test= reproduction of central post wrist pain
• Can also indicate Kienbock disease, carpal instability, joint degeneration, or synovitis

Question 14

Scapulolunate Shear Test

Answer 14

• Patient in sitting with the forearm pronated
• Clinician grasps the scaphoid with one hand
• Clinician grasps the lunate between the thumb and the index finger
• Lunate and scaphoid are then sheared in an anterior then posterior direction
• Positive test=reproduce the patient’s pain and laxity

Question 15

FDS Test

Answer 15

• Used to test integrity of the Flexor Digitorum Superficialis tendon
• Clinician holds the patients fingers in extension, except for the finger being tested
• Patient instructed to flex the finger at the PIP joint
• If this is possible= FDS tendon is intact
• Since this tendon can act independently due to the position of the finger, it is the only functioning tendon at the PIP joint

Question 16

FDP Test

Answer 16

• These tendons work only in unison
• To test the Flexor Digitorum Profundus, the PIP joint and the MCP joints are stabilized in extension
• Patient is asked to flex this finger at the DIP joint
• If flexion occurs= FDP is intact
• If no flexion= tendon is severed or muscle denervated

Question 17

Integrity of the Central Slip

Answer 17

• Patient flexes the finger to 90 at the PIP joint over the edge of the table
• Patient is then asked to extend the PIP joint while the clinician palpates the middle phalanx
• The absence of extension at the distal joint, indicates a complete rupture of the central slip

Question 18

Piano Key Test

Answer 18

• Used to evaluate the stability of the ulnomeniscotriquetral joint
• Clinician firmly stabilizes the distal radius with one hand, grasps the head of the ulna between the thumb and index finger on the other hand
• Ulnar hear is depressed in an anterior direction (like a piano key)
• Positive test= pain and/or excessive movement, or if upon release the bone springs back to high posterior
• Can indicate TFCC tear or triquetral instability

Question 19

Lunotriquetral Shear Test

Answer 19

• Assesses the integrity of the lunotriquetral ligament
• Clinician grasps the triquetrum between the thumb and the second finger of one hand
• Clinician grasps the lunate with the other
• The lunate is moved posteriorly with the thumb of one hand, while the triquetrum is pushed anteriorly in the A/P plane by the index finger of the other hand
• Positive test= crepitus, clicks, or pain

Question 20

Watson Test for Carpal Instability

Answer 20

• Used to examine the dynamic stability of the wrist, in particular the scapholunate ligament
• Patient in sitting with the elbow in approximately 90o of flexion, forearm slightly pronated, and wrist UD
• Clinician grasps the wrist from the radial side and stabilizes the scaphoid tubercle with the thumb and the posterior aspect of the scaphoid with the index finger
• Clinician uses the other hand to grasp the metacarpals
• Starting in UD and slight extension, the wrist is moved into radial deviation and slight flexion
• As the wrist is brought passively into radial deviation, the normal flexion of the proximal row forces the scaphoid tubercle into an anterior direction (into the Clinician’s thumb)
• Clinician attempts to prevent the anterior motion of the scaphoid
• When the scaphoid is unstable, its proximal pole is forced to sublux posteriorly
• Positive test=pain at the posterior wrist or a clunk
• Suggests instability

Question 21

Gamekeeper’s or Skier’s Thumb Test

Answer 21

• Patient in sitting
• Clinician stabilizes the patient’s hand with one hand and takes the patient’s thumb into extension with other
• While maintaining the thumb into extension, the clinician applies a valgus stress to the MCP joint of the thumb to stress the UCL
• Positive test is present if the valgus movement is greater than 30–35 degrees, indicating a complete tear of the UCL and the accessory collateral ligaments

Question 22

Murphy Sign

Answer 22

• Patient is asked to make a fist
• If the head of the third metacarpal is level with the second and fourth metacarpals, the sign is positive for the presence of a lunate dislocation

Question 23

Allen Test

Answer 23

• Used to determine the patency of the vessels supplying the hand
• Clinician compresses both the radial and ulnar arteries at the wrist, and then asks the patient to open and clench the fist 3-4 times to drain the venous blood from the hand
• Patient is then asked to hold the hand open while the clinician releases the pressure on the ulnar artery while maintaining pressure on the radial artery
• Fingers and palm should regain their normal color
• This procedure is repeated with the radial artery released w/compression on the ulnar artery maintained
• Normal filling time is usually less than 5 seconds
• A distinct difference in the filling time suggests the dominance of one artery filling the hand

Question 24

Tinel (Percussion) Test

Answer 24

• Used to assist in the diagnosis of CTS
• The area over the median nerve is tapped gently at the anterior surface of the wrist
• If this produces tingling in the median nerve distribution, then the test is positive

Question 25

APB Weakness for CTS

Answer 25

• Patient is sitting with their hand resting on the table
• Clinician asks the patient to touch the pads of the thumb and small finger together
• Clinician applies a strong force in order to resist thumb abduction
• Positive test=weakness in some abduction with resisted testing as compared to the other hand

Question 26

Phalen Test for CTS

Answer 26

• Patient sitting with wrists flexed and elbows flexed
• Positive test is if the patient experiences numbness or tingling throughout the median nerve distribution of the hand within 30-45 seconds

Question 27

Reverse Phalen Test for CTS

Answer 27

• Patient sitting with wrists extended and elbows flexed
• Positive test is if the patient experiences numbness or tingling throughout the median nerve distribution of the hand within 30-45 seconds

Question 28

Wrist Flexion and Median Nerve Compression Test

Answer 28

• Patient sitting with the elbow fully extended, forearm supinated, and the wrist flexed to 60o
• Clinician applies a constant pressure over the median nerve at the carpal tunnel using the thumb
• Positive test for CTS is the reproduction of symptoms along the median nerve distribution within 30 seconds

Question 29

Median Nerve Compression Test/Pressure Provocation Test

Answer 29

• Patient sitting
• Clinician grasps patient’s hand with thumbs directly over the median nerve as it passes under the flexor retinaculum between the FCR and the palmaris longus
• Gentle pressure applied w/ thumbs for 15-120 seconds
• Positive test is the reproduction of pain, paresthesia, or numbness distal to the site of compression in the distribution of the median nerve

Question 30

Froment Sign

Answer 30

• Used to define weakness in the Adductor Pollicis due to ulnar nerve palsy
• Patient pinches the index finger and thumb together without flexion occurring at the DIP joint (tongue depressor or paper is useful)
• Clinician tried to pull the object from the patient
• Positive test is inability to complete or hold this maneuver (patient will use Flexor Pollicis Longus to compensate)