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Updated: May 23 2021

Physical Exam of the Hand

  • Overview
    • An overview of some of the common physical exam maneuvers used to examine the hand and wrist
      • Common physical exam maneuvers used to examine the hand and wrist
      • Watson test
      • Scapholunate (SL) instability - dynamic
      • Lunotriquetral ballotment test (Reagan test)
      • Lunotriquetral (LT) instability - dynamic
      • Kleinman shear test
      • LT instability - dynamic
      • Lichtman test
      • Midcarpal instability - dynamic
      • TFCC grind
      • TFCC pathology
      • ECU snap test
      • ECU instability
      • Piano key sign
      • DRUJ instability
      • Fovea sign
      • TFCC pathology or ulnotriquetral ligament split tear
  • Inspection
    • Skin
      • discoloration
        • erythema (cellulitis)
        • white (arterial insufficiency)
        • blue/purple (venous congestion)
        • black spots (melanoma)
      • trophic changes (i.e. increased hair growth or altered sweat production)
        • can represent derangement of sympathetic nervous system
      • scars/wounds
    • Swelling
    • Muscle atrophy
      • thenar atrophy
        • median nerve involvement
          • caused by carpal tunnel syndrome
      • interossei atrophy
        • ulnar nerve involvement
          • caused by cubital tunnel or cervical radiculopathy
      • subcutaneous atrophy
        • locally post-steroid injection
    • Deformity
      • asymmetry
      • angulation
      • rotation
      • absence of normal anatomy (previous amputation)
      • cascade sign
        • fingers converge toward the scaphoid tubercle when flexed at the MCPJ and PIPJ
        • if one or more fingers do not converge, then trauma to the digits has likely altered normal alignment
  • Palpation
    • Masses (ganglions, nodules)
    • Temperature
      • warm: infection, inflammation
      • cool: vascular pathology
    • Tenderness
    • Crepitus (fracture)
    • Clicking or snapping (tendonitis)
    • Joint effusion (infection, inflammation, trauma)
  • Range of Motion
    • Active and passive
      • Finger
        • MCP: 0° extension to 85° of flexion
        • PIP: 0° extension to 110° of flexion
        • DIP: 0° extension to 65° of flexion
      • Wrist
        • 60° flexion
        • 60° extension
        • 50° radioulnar deviation arc
  • Neurovascular Exam
    • Sensation
      • two-point discrimination
    • Motor
      • radial nerve: test thumb IP joint extension against resistence
      • median nerve
        • recurrent motor branch: palmar abduction of thumb
        • anterior interosseous branch: flexion of thumb IP and index DIP ("A-OK sign")
      • ulnar nerve: cross-fingers or abduct fingers against resistence
    • Vascular
      • radial pulse
      • ulnar pulse
      • Allen's test
      • capillary refill
  • Special Tests
    • Palpation
      • grind test
        • used to test for pathology at the thumb carpometacarpal joint (CMC)
        • examiners applies axial load to first metacarpal and rotates or "grinds" it
        • positive findings: pain, crepitus, instability
      • Finkelstein's
        • used to test for DeQuervain's tenosynovitis
        • patient makes fist with fingers overlying thumb
        • examiner gently ulnarly deviates the wrist
        • positive findings: pain along the 1st compartment
    • Range of motion
      • flexor profundus
        • used to test continuity of FDP tendons
        • MCP + PIP joints held in extension while patient asked to flex FDP, thereby isolating FDP (from FDS) as the only tendon capable of flexing the finger
      • flexor sublimus
        • used to test for continuity of FDS tendon
        • MCP, PIP and DIP of all fingers held in extension with hand flat and palm up; the finger to be tested is then allowed to flex at PIP joint.
      • Bunnel's test
        • examiner passively flexes PIPJ twice
          • first with MCP in extension
          • next with MCP held in flexion
        • intrinsic tightness present if PIP can be flexed easily when MCP is flexed but NOT when MCP is extended
        • extrinsic tightness present if PIP can be flexed easily when MCP is extended but NOT when MCP is flexed
    • Stability assessment
      • scaphoid shift test (Watson's test)
        • tests for scapholunate ligament tear
        • examiner places thumb on distal pole of scaphoid on palmar side of wrist and applies constant pressure as the wrist is radially and ulnarly deviated
        • dorsal wrist pain or "clunk" may indicate instability
      • lunotriquetral ballottement
        • tests for lunotriquetral ligament tear
        • examiner secures the pisotriquetral unit with the thumb and index finger of one hand and the lunate with the other hand
        • anterior and posterior stresses are placed on the LT joint
        • positive findings are increased laxity and accompanying pain
      • midcarpal instability
        • examiner stabilizes distal radius and ulna with non-dominant hand and moves patients wrist from radial deviation to ulnar deviation, whilst applying an axial load
        • a positive test occurs when a clunk is felt when the wrist is ulnarly deviated
      • ulnar carpal abutement
        • tests for TFCC tear or ulnar-carpal impingement
        • examiner ulnarly deviates wrist with axial compression
        • positive if test reproduces pain or a 'pop' or 'click' is heard
      • Gamekeeper's
        • tests for ulnar collateral ligament tear at MCP of thumb
        • examiner stresses first MCPJ into radial deviation with MCPJ in fully flexed and extended positions
        • positive test if > 30 degrees of laxity in both positions (or gross laxity compared to other side)
    • Nerve assessment
      • Tinel's
        • tests for carpal tunnel syndrome
        • examiner percusses with two fingers over distal palmar crease in the midline
        • positive if patient reports paresthesias in median nerve distribution
      • Phalen's
        • tests for carpal tunnel syndrome
        • with the hands pointed up, the patient's wrist is allowed to flex by gravity in palmar flexion for 2 minutes maximum
        • positive if patient reports paresthesias in median nerve distribution
      • Froment's sign
        • tests for ulnar nerve motor weakness
        • patient asked to hold a piece of paper between thumb and radial side of index
        • positive if as the paper is pulled away by the examiner the patient flexes the thumb IP joint in an attempt to hold on to paper
      • Wartenberg's sign
        • tests ulnar nerve motor weakness
        • patient asked to hold fingers fully adducted with MCP, PIP, and DIP joints fully extended
        • positive if small finger drifts away from others into abduction
      • Jeanne's sign
        • tests for ulnar nerve motor weakness
        • ask patient to demosntrate key pinch
        • positive finding if patients first MCP joint is hyperextended
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