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

Introduction

The hand and wrist form a group of complex, delicately balanced joints which are considered the most active portion of the upper extremity. Optimal overall function is important to so many activities of daily living. A hand and wrist examination done in a structured manner will help to facilitate the most appropriate working diagnosis for treatment. Diagnosing hand and wrist conditions is often difficult and for this reason, bilateral comparison can be useful

Subjective History

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:

• Mechanism of the injury - How the injury occurred and what was the cause e.g. fall on an outstretched hand
• Insidious or sudden injury.
• Handedness, occupation, previous injury and fracture history
• Location of the pain
• Presence and location of numbness, pins and needles and/or tingling.
• Aggravating and relieving factors.
• Functional limitations.
• Were any diagnostic test/imaging performed and what were the results?

Objective Examination

Screen Proximal Joints

Screen proximal structures to determine if they are involved in the patient’s clinical presentation. i.e. Cervical joints, Shoulder, Elbow.

Observation

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

• Observe upper extremity as the patient enters the room
  1. Examine hand in function
  2. Deformities
  3. Attitude of the hand

• Palmar Surface
  1. Creases
  2. Thenar and Hypothenar Eminence
  3. Arched Framework
  4. Hills and Valleys

• Dorsal surface
  1. Hills and Valleys
  2. Height of metacarpal heads
  3. Deformities.

• Ganglions - Cystic structure that arises from synovial sheath

• Boutonniere Deformity

• Swan Neck Deformity (see image)

• 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. (see R)

• Muscle wasting due to nerve dysfunction
  1. Median Nerve (depending on area impingement)

• Muscle wasting in the thenar eminence, first three fingers, and half the fourth fingers on radial side of the hand.
  1. 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. Ulnar Nerve (depending on area of impingement)
  2. Muscle wasting in the hand for the ulnar nerve occurs primarily in the fifth and half the fourth fingers, in the hypothenar area.
     

Functional Tests

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

Palpation

Wrist (Dorsal to Volar)

• Radial Styloid
• Scaphoid
• 1st MC/Trapezium joints
• Lunate
• Lister’s Tubercle
• Ulnar Styloid
• TFCC
• Triquetrum
• Pisiform
• Hook of Hamate
• Guyon’s Tunnel

Palpation of Hand

• Bone
  • Metacarpals - 5, Phalanges - 14, (Palpate for swelling, tenderness)

• Soft tissues
  • 6 Dorsal Compartments – Transport extensor tendons See image at R

1st compartment- De quervains 2nd compartment - Intersection syndrome

Compartment 1 (Most radial)	Compartment 2	Compartment 3	Compartment 4	Compartment 5	Compartment 6 (Most ulnar)
Abductor pollicis longus	Extensor carpi radialis longus	Extensor pollicis longus	Extensor indicis	Extensor digiti minimi	Extensor carpi ulnaris
Extensor pollicis brevis	Extensor carpi radialis brevis		Extensor digitorum communis

2 Palmar Tunnels – Transport nerves, arteries, flexor tendons

Palmar Aspect - Pisiform and Hamate, Tunnel of Guyon, Carpal Tunnel, Flexor Carpi Radialis, Flexor Carpi Ulnaris

Palm of Hand

• Thenar Eminence (3 muscles of thumb, Atrophy seen in carpal tunnel syndrome)

• Hypothenar Eminance (3 muscles of little finger, Atrophy with ulnar nerve compression)

• Palmar Aponeurosis (Dupuytren’s Contracture)
  
  

Neurological Assessment

Upper Extremity Nerve Palpation:

Goal is 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

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
  • Median nerve bias (Upper limb tension test 1 [ULTT] /UpperLimb Tension Test 2a)
  • Radial nerve bias (ULTT2b)
  • 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, Pain on active motion, Pain on passive motion, Pain on grip, Pain on supination

Anyone of the above findings associated with a history of trauma should be sent for radiographs

Additional potentially serious conditions

• Scapholunate instability
• Arthritides
• Rheumatoid Arthritis
• Lyme disease
• Tuberculosis
• Peripheral Vascular Disease
• Peripheral Neuropathy
• History 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

Possible Diagnosis Examples from Examination

• Carpal Tunnel Syndrome
• Anterior Interosseous Syndrome
• Posterior Interosseus 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:
• Grip Strength, functional test.
• 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 two conditions commonly examined – osteoarthritis and rheumatoid arthritis (be familiar with the changes that each of these conditions can cause).