Updated: 10/4/2016

Physical Exam of the Hand

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Overview
  • An overview of some of the common physical exam manoeuvers used to examine the hand and wrist
Test
Tests instability at
Watson test post Scapholunate (SL) instability - dynamic
Lunotriquetral ballotment test (Reagan test) post 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 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) Wrist 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 Finger range of motion
      • MCP: 0° extension to 85° of flexion
      • PIP: 0° extension to 110° of flexion
      • DIP: 0° extension to 65° of flexion
    • Wrist
    •  
      • 60° flexion Wrist flexion/extension
      • 60° extension
      • 50° radioulnar deviation arc Radioulnar deviation arc
Neurovascular Exam
  • Sensation Sensory territories and innervations of the hand
    • 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 Thumb CMC joint 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 Finkelstein's test
      • 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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