Wrist/Hand Flashcards
Thumb CMC Grind Test
The purpose of the Thumb CMC Grind Test is to assess the integrity of the thumb CMC joint. Reproduction of the patient’s pain and crepitus is a positive test for arthrosis and synovitis. Therapists must be aware of the crank test which both evaluates the joint quality and translational laxity, the distraction test where a pain response indicates joint inflammation and volar compression of the first metacarpal base which also indicates joint inflammation
The grind test is performed by gripping the patient’s metacarpal bone of the thumb and moving it in a circle and loading it with gentle axial forces. A patient with thumb joint arthritis generally complains of a sudden sharp pain at the CMC joint which can also be associated with Crepitus[2]. This indicates a positive test
Froment’s Sign
Froment’s sign is a physical examination of the hand to test for palsy of the ulnar nerve which results in reduced functionality and muscle weakness of the pinch grip. It tests the strength of the adductor pollicus of the thumb, which is innervated by the ulnar nerve and is weakened in ulnar nerve palsy.
Froment’s sign presents after damage to the ulnar nerve, which innervates the adductor pollicis and interossei muscles, which provide adduction of the thumb and extension of the interphalangeal joint. The flexor pollicis longus (innervated by the median nerve), will substitute for the adductor pollicis (innervated by the ulnar nerve) and cause the thumb to go into hyperflexion. Ulnar nerve palsy can be as a result of dysfunction at the cervical spine, elbow (cubital tunnel syndrome) or at the wrist (Guyons canal syndrome).
Technique
The patient is asked to make a strong pinch between the thumb and index finger and grip a flat object such as a piece of paper between the thumb and index finger. The examiner then attempts to pull the object out of the subject’s hands. There is weakness of the adductor pollicus innervated by the ulnar nerve which would keep the IP joint relatively straight; instead, the FPL muscle which is innervated by the median nerve is substituted for the AP and will cause the IP joint to go into a hyperflexed position.
Phalen’s Test
Purpose
To test for carpal tunnel syndrome (CTS)
Clinically Relevant Anatomy
Median Nerve
Formed by the spinal roots C6, C7, C8, T1.
C6 innervates –>lateral side forearm –>wrist extensors
C7 innervates –> middle finger –>wrist flexors
C8 innervates –>medial side of forearm, ring finger and little fingers flexors like
T1 innervates –>medial side of upper arm
Innervates: Pronator teres, Palmaris longus, Flexor carpi radialis, Flexor digitorum superficialis, Flexor digitorum profundus (lateral half), Pronator quadratus, Flexor pollicis longus, Abductor pollicis brevis, Opponens pollicis, Flexor pollicis brevis, and Lumbricals 1 and 2
Summary of CTS
The phalen’s test is a provocative test used in the diagnosis of CTS. This occurs when the median nerve is compressed or squeezed at the wrist. [4C,5F] The pain is often worst at night. Daily activities such as driving and typing may increase the symptoms. [5F] The most common complaints are;
pain and tingling of hands and fingers
numbness in the fingers (specifically the thumb, forefinger and a part of the middle finger)
pain in or near the wrist. [9F]
pain extending into the arm (less frequent)
skin lesions in the territory of the median nerve are possible due to compression of blood vessels in the carpal tunnel
Technique[1]
The patient places her flexed elbows on a table, allowing her wrists to fall into maximum flexion. The patient is asked to push the dorsal surface of her hands together and hold this position for 30-60 seconds. This position will increase the pressure in the carpal tunnel, in effect compressing the median nerve between the transverse carpal ligament and the anterior border of the distal end of the radius.
Another way to describe the standard Phalen’s test: the patient leaves his / her elbows bent between 0 ° -30 °. Then the therapist asks the patient to supinate his / her forearm. After this the therapist carries a maximum palmar flexion of the wrist and holds it for 60 seconds. During the test the patient will be asked to explain each 15 seconds what she feels. [7C]
Reverse Phalen’s test. The patient maintains a position of full wrist and finger extension for two minutes. The pressure on the carpal tunnel increases after 10 seconds (compared to 20-30 seconds for the standard Phalen test). The longer the position is held, the greater the pressure on the wrist and carpal tunnel.
Wartenberg’s Sign
Wartenberg’s Sign refers to the slightly greater abduction of the fifth digit, due to paralysis of the abducting palmar interosseous muscle and unopposed action of the radial innervated extensor muscles (digiti minimi, digitorum communis ).[1]This should not be confused with Wartenberg’s Syndrome which is described as the entrapment of the superficial branch of the radial nerve with only sensory manifestations and no motor deficits.
Patients with SRN compression typically report pain or dysesthesias on the dorsal radial forearm radiating to the thumb and index finger, although the distribution of symptoms may vary owing to differences in anatomy. When such sensory disturbances present concomitantly with weakness of the PIN-innervated muscles, the clinician should consider alternative diagnoses, such as a more proximal lesion (of the cervical spine, posterior cord of the brachial plexus, or radial nerve proper) or perhaps a mass in the radial tunnel large enough to affect both the PIN and SRN.
Because irritation of the SRN often occurs in the region of the first dorsal compartment, SRN compression symptoms may be confused with the symptoms of de Quervain’s tenosynovitis owing to pain with ulnar deviation of the wrist. One principal difference between the two conditions is that patients with SRN compression tend to have symptoms at rest, independent of the position of the wrist and thumb.
SRN compression and de Quervain’s tenosynovitis may in fact both be present simultaneously. A positive Tinel’s sign over the course of the SRN is the most common physical examination finding, although the clinician should be mindful that this may also be positive in patients with more proximal pain generators, such as a lateral antebrachial cutaneous neuritis.[Finkelstein’s test may be misleadingly positive as the thumb does not have to be flexed to elicit a positive test.
