Wrist and Hand 201wrist and hand eval 4

Wrist and hand

2014

© Division of Physiotherapy, Department of

Interdisciplinary Science, Faculty of Health Science, Stellenbosch University. 2012. All

rights reserved.

MODULE: PHYSIOTHERAPY SCIENCE 272 SUB-MODULE: EVALUATION

THEME: JOINTS

Outcomes

• Demonstrate appropriate and accurate observation of the wrist and hand.

• Perform all the examination techniques of the wrist and hand with skill.

• Measure the ROM of the wrist and hand accurately.

• Distinguish between normal and abnormal ROM and endfeel.

• Apply biomechanical knowledge.

• Perform the physical examination systematically.

• Choose appropriate examination procedures.

• Determine the affected structures from the examination.

• Motivate all the examination techniques and explain the principles thereof.

© Division of Physiotherapy, Department of Interdisciplinary Science, Faculty of Health Science, Stellenbosch University. 2012. All rights reserved.

Basic Anatomy (revision)

• Name the bones of the wrist and hand:

• Name all the joints in the wrist and fingers:

• Describe the joints at the thumb:

• Describe the shape of the joint surfaces of the wrist, fingers and thumb (concave/convex).

• Describe the arthrokinematic movements during

- Wrist flexion

- Wrist extension


• Radius

• Ulnar

• 8 x carpals (Pisiform; Triquetrum; Lunate; Scaphoid/Hamate; Capitate; Trapezoid; Trapezium)

• 5 x Metacarpals

• 14 x Phalanges

• Styloid processes (radial/ulnar)

• Lister tubercle

© Division of Physiotherapy, Department of Interdisciplinary Science, Faculty of Health Science, Stellenbosch University. 2012. All

rights reserved.

Bones of the Wrist & Hand

• Inferior radioulnar joint (IRUJ)

• Radiocarpal joint (RCJ)

• Midcarpal/intercarpal joint (MCJ)

• Carpometacarpal joint (CMJ)

• Metacarpophalangeal joint (MPJ)

• Proximal and Distal Interphalangeal joint (PIPJ & DIPJ)

Joints at the thumb

The thumb has a CMJ, MPJ and 1 x IPJ. It articulates with the trapezium proximally.


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Joints of the Wrist & Hand

• RCJ - proximally → single biconcave curvature, and distally → single biconvex curvature (ellipsoid)

• MCJ→ overall reciprocally concave-convex i.e. does not form one uninterrupted articular surface (glide)

• CMJ - proximally → concave, and distally → convex (1st joint ellipsoid/saddle)

• MPJ→ concave proximal phalanx & convex distal metacarpal (ellipsoid)

• IPJ →base of each middle and distal phalanx has two shallow concave faces with a central ridge. True uniaxial hinge joint (hinge)


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Joint surfaces of the Wrist & Hand

• Open chain movement = the convex surfaces of the scaphoid and lunate move on the concave surfaces of the radius and ulna.

• Flexion: scaphoid/lunate roll anteriorly (toward palm) and glide posteriorly (toward dorsum)

• Extension: scaphoid/lunate roll posteriorly (toward dorsum) and glide anteriorly (toward palm).


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Arthrokinematic mvts of the Wrist flex/ext

Observation


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• Informal

• Formal

Informal observation

• Observe the patient in static and dynamic situations/gestures/use of hand

• Observe the quality of mvt

• Also observe the posture and facial characteristics of the patient

• Remember that informal observation begins when the patient walks into the room and ends when he/she walks out of the room at the end of the session.


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Formal observation General

• Posture

• Pt’s posture in sitting and standing

• Posture of the head and neck

• Thoracic spine and shoulders

• Look for abnormal posture of the hand e.g. Dropped wrist and fingers (radial nerve palsy)/Clawing of the ulnar two fingers (ulnar nerve palsy)/adducted thumb (median nerve palsy)

• Correct any asymmetry passively to determine relevance to pt’s problem.

• Swelling/joint effusion © Division of Physiotherapy, Department of Interdisciplinary Science, Faculty of

Health Science, Stellenbosch University. 2012. All rights reserved.

Skin condition

• Colour of skin

• Any scars/contractures

• Increased hair growth

• Brittle nails

• Infection of the nail bed

• Sweating or dry palm

• Shiny skin

• Changes could be indicative of a peripheral injury, peripheral vascular disease, DM, complex regional pain syndrome


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Common deformities: • Swan-neck deformity – PIPJ hyperext, DIPJ fexed • Boutonnière deformity- PIPJ flex, DIPJ ext • Claw hand – little and ring finger: hyperext MPJ, flex IPJ • Mallet finger-rupture of terminal ext tendon at DIPJ • Clinodactyly – congenital radial deviation of distal

joints of fingers (mostly little finger) • Camptodactyly – congenital flexion contracture

PIPJ/DIPJ • Herbeden’s nodes - osteoarthritis • Bouchard’s nodes - Rheumatoid arthritis • Club nails - respiratory/cardiac disorders


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Muscle mass

• Compare left and right muscle tone and bulk

• Identify muscles

• Check for atrophy of specific muscles, such as the first dorsal interosseous muscle supplied by the ulnar nerve, opponens pollicis supplied by the median nerve.

• Thenar/hypothenar eminence bulk

• Remember that the dominant hand affects the level of dexterity and due to the higher frequency of use, a larger muscle bulk


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• Anterior

• Position of the wrist and fingers

• Palmar fascia/arches of the hand/contractures

• Lateral

• Alignment/position (F/E)

• Bony prominences

• Posterior

• Bony alignment, joints

• Web spaces

• Ganglions


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Functional/Reproducing movement

• Problematic movement

• E.g. Coming hair/holding cup/power grip/spherical grip/precision grip

• Weight-bearing vs traction activities


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Active Physiological movements

• IRUJ Supination/pronation

• RCJ flexion/ext

• RCJ radial/ulnar deviation

• CMJ flex/ext, adb/add and opposition

• MPJ flex/ext, abd/add

• PIPJ and DIPJ flex/ext


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Passive Physiological mvts: Hand placements

Movement & Endfeel Execution

Flexion (firm ) Grab wrist & hand by both hands

Extension (firm/hard) R hand supports forearm, L hand takes wrist into extension

Radial Deviation (hard/firm) R hand supports just proximal to wrist joint, while L hand moves wrist

Ulnar Deviation (firm) A/A

Flexion of fingers (firm/hard) R hand supports carpus

Extension of the fingers (firm/hard) A/A

Abduction of fingers(firm) Stabilize carpus, use index finger and thumb for mvt

Adduction of fingers (firm) A/A


Capsular Pattern

• Inferior radioulnar joint: full range but pain at extremes of range

• Wrist: flexion and extension equally limited

• Carpometacarpal joint of the thumb: full flexion, more limited abduction than extension

• Thumb and finger joints: more limitation of flexion than of extension


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Close-packed position

• Position in which the joint surfaces are maximally congruent an the ligaments and capsule are maximally taut. E.g. Full extension of IP joints


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Flex. Ext. R.D U.D Abd Add

Wrist 80-85° 70-80 ° 20-25 ° 30-35 °

MP 90 ° 30-45 ° 20 °

PIP 100 ° 0 °

DIP 90 ° 0 °

Thumb MP 50 ° 50 ° 70 ° 0 °

Thumb IP 90 ° 20 °

Goniometry

Wrist Flexion Wrist Extension

Triquetrum Midpoint Triquetrum OR

Capitate

(lat midline ulna)

Olecranon & Ulnar

styloid process

Proximal

reference

point

(lat midline ulna)

Olecranon & Ulnar styloid process

Or midline of forearm

(lat midline)

5th metacarpal

Distal

reference

point

(lat midline)

5th metacarpal OR midline 3rd

metacarpal


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Radial Deviation Ulnar Deviation

(middle of dorsal

aspect of wrist)

Capitate

Midpoint (middle of dorsal aspect of

wrist)

Capitate

Lateral epicondyle of

the humerus

Proximal

reference

point

Lateral epicondyle of the

humerus

3rd metacarpal

Not 3rd phalanx

Distal

reference

point

3rd metacarpal

Not 3rd phalanx


Isometric muscle tests Wrist

Flexion Flexor carpi radialis, palmaris longus,

Flexor carpi ulnaris

Extension Extensor carpi radialis longus, Extensor

carpi radialis brevis, Extensor carpi

ulnaris

Pronation Pronator teres, pronator quadratus

Supination Supinator

Radial deviation Abductor pollicis longus, Extensor

pollicis brevis

Ulnar Deviation Flexor carpi ulnaris, Extensor carpi

ulnaris


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Fingers

Flexion Flexor digitorum superficialis,

profundus, lumbricals; Flexor digiti

minimi, Adductor digiti minimi

Extension Extensor digitorum, lumbricals

Abduction Interosseous (dorsal), Abductor digiti

minimi

Adduction Interosseous (palmar)

Thumb Flexion Flexor pollicis brevis,

Thumb Extension Extensor pollicis brevis, Extensor

pollicis longus, Abductor pollicis longus

Thumb Abduction Abductor pollicis longus

Thumb Adduction Adductor pollicis

Thumb opposition Opponens pollicis

© Division of Physiotherapy, Department of Interdisciplinary Science, Faculty of Health

Science, Stellenbosch University. 2012. All rights reserved.

Palpation Examination

• Temperature

• Skin moisture

• Bony alignment

• Soft tissue structures – muscle bulk/tendon tightness

• Oedema/effusion

• Mobility and feel of Ganglions/nodules/Scar tissue

• Muscle spasm

• Nerves

• Tenderness


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Passive accessory movements Radiocarpal joint • ↑ & ↓ Left hand: grasp around the distal end of the radius and ulna Right hand: grasp the hand at the level of the proximal end of the

metacarpals and glide the pt’s hand anteriorly and posteriorly


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• ← med & → lat transverse

Hands grasp around the distal radius and ulna and proximal end of the metacarpals.

Right hand glides the pt’s hand medially and laterally


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• ↔ caudad

Grasp around the distal radius and ulna and the proximal end of the metacarpals.

Right hand: pull the hand away from the wrist.


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• ↔ cephalad

Grasp around the distal radius and ulna with the left hand.

Use the right hand to apply a longitudinal force to the wrist through the heel of the hand.


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Intercarpal joint

• ↑ & ↓

Apply pressure with your thumb to the anterior or posterior aspect of each carpal bone.


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Carpo-Metacarpal Joint

• ↑ & ↓

Left hand grasps around the relevant distal carpal bone

Right hand grasps the proximal end of the metacarpal and glides the metacarpal forwards and backwards.


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Metacarpo-phalangeal & interphalangeal joints

Left hand grasps and supports the head of the metacarpal

Right hand grasps the proximal phalanx

• ↑ &↓

Glide the proximal phalanx posteriorly and anteriorly with right hand


• ← med & →lat

Glide the proximal phalanx sideways with the right hand


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Special Tests

• Differentiation tests

• Joint integrity tests

• Sweater finger sign test

• Carpal tunnel syndrome (Phalen’s test)

• De Quervain’s disease (Finkelstein test)

• Linburg’s sign (tendonitis)

• Allen test (artery patency test)

• Thoracic outlet syndrome

• Hand volume test © Division of Physiotherapy, Department of Interdisciplinary Science, Faculty of Health Science, Stellenbosch University. 2012. All

rights reserved.

Differentiation Tests • Differentiation between RCJ and IRUJ

If supination reproduces symptoms =

- Passively move forearm into supination to the point where the symptoms are reproduced.

- Inc. supination at the IRUJ by applying a supination force to the distal radius and ulna.

- Increase in symptoms = IRUJ cause of symptoms. Confirm by establishing that increasing supination of the hand has no effect on symptoms.


Joint integrity tests

• Ligamentous instability test

• Watson’s scaphoid shift test

• Lunotriquetral bollottement test

• Midcarpal test


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Ligamentous instability test

• Ligamentous instability test for the joints of the thumb and fingers

• Excessive movement when an abduction or adduction force is applied to the joint is indicative of joint instability due to laxity of the collateral ligaments


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Watsons scaphoid shift test

• Apply an anterior glide to the scaphoid while passively moving the wrist from a position of ulnar deviation and slight extension to radial deviation and slight flexion.

• Posterior subluxation of the scaphoid and/or reproduction of pt’s pain indicates instability of the scaphoid.


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Lunotriquetral bollottement test

• Instability at joint between lunate and triquetral bones

• Excessive movement, crepitus or pain with posterior and anterior glide of the lunate on the triquetrum indicates a positive test


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Sweater finger test

• Loss of distal IPJ flexion when making a fist

• Ruptured flexor digitorum profundus tendon


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Tinel’s sign

• First detectable sign of nerve damage or regeneration

• Tap from distal to proximal along the line of the nerve

• Until pt feels “pins and needles”

• Most distal point of ‘pins and needles” –furthest point of axonal regeneration or compression of nerve


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Carpal tunnel syndrome (Phalen’s test)

• Median nerve test

• 1 minute sustained bilateral wrist flexion

• Paraesthesia production along the median nerve indicates a positive test

• Reverse Phalen’s test: pt makes fist with wrist in extension, PT applied pressure for 1 minute


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De Quervain’s disease (Finkelstein test)

• Pt makes fist with thumb inside the fingers

• passive ulnar deviation of wrist by PT

• Reproduction of symptoms: indicative of de Quervain’s disease (tedosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons)


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Linburg’s sign (tendonitis)

• At interconnection between flexor pollicis longus and flexor indices

• Thumb flexed over onto the hypothenar eminence and index finger extended

• Limited range = positive test


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Allen test (artery patency test)

• If circulation is suspected of being compromised

• PT applies pressure to radial/ulnar arteries; Pt open and close hand few times, then keep it open; PT releases pressure; Hand should flush within 5 secs

• Thoracic outlet syndrome: with pt sitting and arm abducted to 90˚, PT horizontally extends and laterally rotates arm. Disappearance of radial nerve indicates thoracic outlet syndrome


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Hand volume test

• To measure swelling of hand

• Difference of 30 to 50ml between hand measurements = significant hand swelling

• Tape measure

• Compare sides


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Wrist and Hand 201wrist and hand eval 4

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