Wrist and Hand Examination

Original Editor - Adam Ruff and Christian Filer as part of the Temple University EBP Project

Top Contributors - Christian Filer, Lucinda hampton, Kim Jackson, Admin, Rachael Lowe, Anas Mohamed, Laura Ritchie, Kai A. Sigel, Shaimaa Eldib, Tony Lowe, Alan Jit Ho Mak, Temitope Olowoyeye, Claire Knott, Scott A Burns, Evan Thomas, Scott Buxton, Naomi O'Reilly, WikiSysop, Fasuba Ayobami, Vidya Acharya, Wanda van Niekerk and Adam Ruff

Subjective

Thorough history taking is an important first step in treating the patient. Each physical therapist will develop their own style and technique, but a good interview will include the basic elements discussed below.

History

Clinical Presentation

1. Mechanism of the injury - How the injury occurred and what was the cause eg fall on outstretched hand
2. Insidious or sudden injury.
3. Handedness, occupation, previous injury
4. Location of the pain
5. Presence and location of numbness and tingling.
6. Aggravating and relieving factors.
7. Functional limitations.
8. Were any diagnostic test/imaging performed and what were the results?

Objective

Observation

Start by watching this 8 minute video of a wrist and hand examination.

Observe upper extremity as patient enters room

• Examine hand in function
• Deformities
• Attitude of the hand

Palmar Surface

• Creases
• Thenar and Hypothenar Eminence
• Arched Framework
• Hills and Valleys

Doral surface

• Hills and Valleys
• Height of metacarpal heads
• Deformities.

Ganglions - Cystic structure that arises from synovial sheath

Boutonniere Deformity

Swan Neck Deformity

Osteoarthritis - Heberden’s nodes: DIP, Bouchard’s nodes: PIP

Dupuytren’s Contractures

Rheumatoid Arthritis - MCP swelling, Swan neck deformities, Ulnar deviation at MCP joints, Nodules along tendon sheaths.

3. Muscle wasting due to nerve disfunction

• Median Nerve (depending on area impingement)

Muscle wasting in the first three and fingers and half the fourth fingers on radial side of the hand. The muscle involved LOAF) are:

1. Lumbricals
2. Oppenens pollicis
3. Abductor pollicis brevis,
4. Flexor pollicis brevis

• Radial Nerve (depending on area of impingement)
  

Common muscles that are affected by radial nerve entrapment are primarily on the dorsal aspect of the hand.

1. Supinator
2. Extensor carpi ulnaris
3. Extensor digitorum communis
4. Extensor digiti quinti
5. Abductor pollicis longus
6. Extensor pollicis brevis
7. Extensor indicis propius

Ulnar Nerve (depending on area of impingement)

• Muscle wasting in the hand for the ulnar nerve occurs primarily in the fifth and half the fourth fingers, in the hypothenar area. The muscles that are affected are:

1. Abductor digiti minimi
2. Opponens digiti minimi
3. Flexor digiti minimi
4. 3rd and 4th lumbrical
5. 1st -3rd palmar interosseous
6. 1st – 4th dorsal interosseous
7. Flexor pollicis brevis
8. Adductor digiti minimi

Screen Proximal Joints

Screen proximal structures to determine if they are involved in the patient’s clinical presentation. Common ways physical therapists may screen these proximal structures include
Cervical

1. Accessory motion testing
2. ROM with over pressures
3. ULNT1(Upper limb neurodynamic test

Shoulder

1. Passive ROM with overpressure
2. Muscle strength testing

Elbow

1. Passive ROM, active ROM with over pressure
2. Muscle strength testing

Functional Tests

Goals - to obtain and quantify an asterisk to assess/reassess after intervention is performed. eg turning door knob, holding a key, initial pain free grip or key grip, opening a jar, turning on tap, lifting saucepan. Grip strength can also be good reliable tool to use (available cheaply on internet).

Palpation

1.Wrist/hand

• Joints of wrist, carpus, MCP, DIP and PIPs
• Extensor Pollicus Brevis/Abductor Pollicus Longus tendons
• Scaphoid
• Anatomical snuff box
• Guyon’s canal
• Distal to lister’s tubercle
• Lunotriquetral joint/fovea for Triangular Fibrocartilaginous Complex
• Any swellings or deformities eg ganglions, nodules.
  

Neurologic Assessment

Upper Extremity Nerve Palpation: Goal To reproduce symptoms if a peripheral nerve entrapment diagnosis is suspected.

To palpate the 3 major nerves of the upper extremity refer to the figure below.

Median: Position patient supine, 90 degrees of shoulder abduction and elbow extension. Palpate medially to the bicep (mid humeral). Palpate distally at wrist.
Radial: Upper arm (0 degrees of abduction, palpate proximal to the lateral epicondyle), distal radius, and snuffbox
Ulnar: Upper arm (medial mid humeral area, shoulder 90 degrees of abduction, elbow 120 degrees of flexion) and cubital tunnel

(Adapted from Schmid et al 2009)

Reflexes - C5-C7

Myotomes - C5-T1

Dermatomes - C5-T1

Movement Testing

If patient is pain free to end range, the physical therapist may choose to apply overpressure.

Wrist

1. Flexion/Extension
2. Radial/Ulnar deviation

• 1st CMC

1. Extension
2. Abduction
3. Opposition

Metacarpal-phalangeal (MCP)

1. Flexion
2. Extension
3. Abduction/Adduction

Inter-phalangeal (IP)/Distal IP/Proximal IP

1. Flexion
2. Extension

Strength Testing

1. Wrist flexion/extension
2. Forearm pronation and supination
3. Grip strength
4. Key and pinch grip strength

Special Tests

The physical therapist may elect to perform various special tests during the physical examination of an individual with wrist or hand complaints. Below are potential tests that may be utilized categorized by possible diagnosis or tissue involvement.

Scaphoid Fracture clinical examination (Anatomical snuff box tenderness; Scaphoid tubercle tenderness; Axial loading of the thumb)

Neurodynamic tests

1. Median nerve bias (Upper limb tension test 1 [ULTT] /UpperLimb Tension Test 2a)
2. Radial nerve bias (ULTT2b)
3. Ulnar nerve bias (ULTT3)

Carpal tunnel syndrome (Carpal compression test; Tinel’s test; Wrist-ratio index)

Scapholunate instability (Scaphoid Shift test)

DeQuervain’s syndrome (Finkelstein Test)

Red Flags

This section deals with screening the patient for possible serious pathologies that could cause wrist or hand pain. These conditions could warrant a referral, or consultation.
Infections

• Heat
• Swelling
• Pain
• Redness
• Inflammation

Fracture/dislocation:

Top five physical findings which are most useful in screening for wrist fracture.

• Localized tenderness (Sensitivity [Sn] 94%)
• Pain on active motion (Sn 97%)
• Pain on passive motion (Sn 94%)
• Pain on grip (Sn 71%)
• Pain on supination (Sn 68%)
• Bottom line: Any one of the above findings associated with a history of trauma should be sent for radiographs

Colles fracture
Scaphoid fracture

Additional potentially serious conditions

• Scapholunate instability
• Arthritedes
• Rheumatoid Arthritis
• Lyme disease
• Tuberculosis
• Peripheral Vascular Disease
• Peripheral Neuropathy
• Hx of trauma, fall on outstretched hand (FOOSH). Older age, >65. The risk is same for men/women
• Upper extremity nerve injuries involving :Median; Radial; Ulnar

Differential Diagnosis

• Carpal Tunnel Syndrome
• Anterior Interosseous Syndrome
• Posterior Interousseous Syndrome
• Distal Radial Fractures
• Osteoarthritis
• First Carpometacarpal Osteoarthritis
• Hand and Wrist Osteoarthritis
• DeQuervain Syndrome
• Radial Tunnel Syndrome
• Compression of the Ulnar nerve at Guyon’s canal
• Non-specific wrist pain (mechanical wrist pain)
• Trigger Finger
• Complex Regional Pain Syndrome
• Triangular Fibrocartilaginous Complex
• Dupuytren’s Contracture

Outcome Measures

• DASH:
• Quick DASH
• Symptom Severity Scale
• Patient Specific Functional Scale

Conclusion

Hand and wrist complaints are common presentations to physiotherapy clinics. Some practices are special "hand" clinics. Being able to perform a thorough examination is vital.

• Common acute problems include fractures, tendonitis and trigger finger.
• Common chronic problems include carpal tunnel syndrome, ganglions and arthritis.
• There are three main conditions commonly examined on in this station – osteoarthritis, rheumatoid arthritis and psoriatic arthritis.
• You should therefore be familiar with the changes that each of these conditions can cause.

References

1. Cevik AA, Gunal I, Manisali M, et al. Evaluation of physical findings in acute wrist trauma in the emergency department. Ulus Travma Acil Cerrahi Derg. 2003;9(4):257-261.
2. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine (Phila Pa 1976). 2003;28(1):52-62.
3. Schmid AB, Brunner F, Luomajoki H, et al. Reliability of clinical tests to evaluate nerve function and mechanosensitivity of the upper limb peripheral nervous system. BMC Musculoskelet Disord. 2009;10:11.