Wrist & Hand Assessment and General View Done by; Mshari S. Alghadier BSc Physical Therapy RHPT 366 m.alghadier@sau.edu.sa http://faculty.sau.edu.sa/m.alghadier/
Functional anatomy The hand can be divided into two major parts: The wrist. Five digits. Composed of eight small bones. It can accommodate movement in three planes. The greatest degree of freedom is in; Flexion extension plane. Ulnar radial deviation. Rotation about the long axis of the forearm. 2
Functional anatomy 3
Functional anatomy Because of its vascular supply, fracture of the scpahoid can lead to avascular necrosis and collapse of the proximal half of that bone. This damage leads to impairment of wrist function and progressive osteoarthritis of the wrist joint. The carpal tunnel, which contains the median nerve together with the flexor tendons of the digits, and the tunnel of Guyon, which contains the ulnar nerve. 4
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Functional anatomy Compression injury of the ulnar nerve will affect the medial aspect of the hand, with the ulnar intrinsic muscles of the hand. This muscular compromise will lead to classic posturing of the digits called the benediction hand, referring to the appearance of a priest s hand when giving a blessing. 6
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Functional anatomy The benediction hand deformity results from damage to the ulnar nerve. There is wasting of the interosseous muscles, the hypothenar muscles, and the two medial lumbrical muscles. 8
Functional anatomy 9
Observation The examination should begin in the waiting room. Is the arm relaxed at the side or is the patient cradling it for protection? Note whether the wrist or hand is edematous. Note the shape of the hand and if there are any changes in contour. Any deformity. 10
Observation The patient may have a swan neck, boutonni`ere deformity, or claw fingers 11
Observation Compare one hand to the other, remembering that the dominant hand may be larger in the normal individual. Will he or she allow you to shake their hand? Is the movement effortless and coordinated or stiff and uncoordinated? Watch the patient if he/she push ups and use his hands to stand from sitting. 12
Observation Clubbing and cyanosis of the nails may be secondary to pulmonary disease. 13
Observation Posture and standing position. Note the height of the shoulders and their relative positions. Arm swing can be limited by either loss of motion, pain, or neurological damage. Observe for symmetry of bony structures. Observe for areas of muscle wasting that may be secondary to peripheral nerve lesions. 14
Subjective Examination The wrist and hand are extremely active structures and complicated. Non-weightbearing, problems are; Overuse syndromes, inflammation, and trauma. Nature and behavior, location and onset of pain. Functional limitation and what is the dominant hand. Does the patient regularly participate in any vigorous sport activity that would stress the wrist or hand? 15
Subjective Examination What is the patient s occupation computer?? If there is a trauma? What was the mechanism of the injury? The direction of the force. The position of the upper extremity. The activity the patient was participating in at the time of the injury. Previous history of the same injury? The most common nerve roots that refer pain are C6, C7, C8, and T1. 16
Gentle palpation The palpatory examination is started with the patient in the sitting position. You should first examine for areas of; Localized effusion, discoloration, birthmarks, open sinuses or drainage, incisions, bony contours, muscle girth and symmetry, and skinfolds. Use firm and gentle pressure to allocate the malposition or deformities. If you harm the Pt in this part of examination the Pt will be afraid and you ll lose his confidence. 17
Gentle palpation The sitting position with the extremity supported on a table is preferred for ease of examination of the wrist and hand. For palpation, the hand should be in the anatomical position. 18
Gentle palpation A. Anterior (palmar) aspect; 1. Boney Structures; Thick skin and fascia covered the palm. 2. Soft-Tissue Structures; Many sweat glands but free of hair. Medial (Ulnar) Compartment; Flexor Carpi Ulnaris. Ulnar Artery. Ulnar Nerve. Hypothenar Eminence. 19
Gentle palpation Middle compartment; Palmaris Longus. Flexor Digitorum Profundus and Superficialis. Carpal Tunnel. Palmar Aponeurosis. Lateral (Radial) Compartment; Flexor Carpi Radialis. Radial Artery. Thenar Eminence. 20
Gentle palpation B. Medial (Ulnar) Aspect; 1. Bony Structures; Ulna Styloid Process. Triquetrum. Pisiform. Hamate. 2. Soft-Tissue Structures; Triangular Fibrocartilaginous Complex. 21
Gentle palpation C. Lateral (Radial) Aspect; 1. Bony Structures; Radial Styloid Process. Scaphoid (Navicular). Trapezium and Trapezoid (Greater and Lesser Multangular). First Metacarpal. 2. Soft-Tissue Structures; Anatomical Snuffbox. 22
Gentle palpation D. Posterior (Dorsal) Aspect; 1. Bony Structures; Dorsal Tubercle of the Radius (Lister s Tubercle). Lunate. Capitate. Metacarpals. Metacarpophalangeal Joints. Phalanges and Interphalangeal Joints. Nails. 23
Gentle palpation 2. Soft-Tissue Structures; Extensor Retinaculum. Compartment I. Compartment II. Compartment III. Compartment IV. Compartment V. Compartment VI. 24
Special Tests A. Tests for ligament, capsule & joint instability; Watson s (Scaphoid shift) Test; This test is used to diagnose abnormal separation of the lunate and scaphoid bones. The examiner takes the patient wrist into ulnar deviation and slight extension with one hand. The examiner presses the thumb of the other hand against the scaphoid to prevent it from moving toward the palm. With other hand, examiner radially deviates and slightly flexes the patient s hand while maintain the pressure on scaphoid. 25
The Watson s Test 26
Special Tests B. Tests Tendons and Muscles; 1) Bunnel Littler Test (Intrinsic Muscles Versus Contracture); Tests the structures around the matacarpophalangeal joint. Meatacarpophalangeal joint held slightly extended while the examiner moves the proximal interphalangeal joint into flexion. Positive; inability to flex the proximal interphalangeal joint, due to tight intrinsic muscle or contracture of the joint capsule. If the metacarpophalangeal joints are slightly flexed, the proximal interphalageal joints flexes fully if the intrinsic muscle are tight. But it dose not flex fully if the capsule is tight. http://www.youtube.com/watch?v=clhztadxexs 27
Special Tests 2) Finkelstein s Test (de Quervain s or Hoffmann s Syndrome); This test is used to diagnose tenosynovitis of the first dorsal compartment of the wrist, which contains the tendons of the abductor pollicis longus and extensor pollicis brevis muscles. Having the patient place the thumb inside the closed fist. Take the patient s hand and deviate the hand and wrist in the ulnar direction to stretch the tendons of the first extensor compartment. Pain over the radial styloid process is pathognomonic of de Quervain s syndrome. 28
Special Tests C. Tests for neurological dysfunction; 1) Tinel s Sign (at the wrist); The examiner taps over the carpal tunnel over the wrist, positive test cause tingling or paresthesia into the thumb and index finger, and middle and lateral half of the ring finger. Its indicative for carpal tunnel syndrome. It should be distally to the point being pressed. 29
Special Tests D. Tests for circulation and swelling; Allen s Test; Used to check the patency of the radial and ulnar arteries at the level of the wrist. http://www.youtube.com/watch v=oycrz1vaehi&feature=related 30
Special Tests 31
Want to do! 1. Tennis elbow. 2. Golfer elbow. 3. Carpal Tunnel syndrome. 4. Major hand deformity. 5. De Quervain s Syndrome 6. Medial & Lateral Epicondlytis. 32
Thank you 33
References, Musculoskeletal Examination, 3rd Edition Jeffrey M. Gross, chapter 10. Orthopedic Physical Assessment, 5th edition, David J. Magee, chapter 7. 34