Clinical Examination Guide

Wrist and Hand

Components of the examination

• Introduction • Look • Feel • Move - active movements • Special Tests - Tinel’s and Phalen’s test for carpal tunnel syndrome - Tinel’s sign for cubital tunnel syndrome - Finkelstein test for De Quervain’s tenosynovitis • Neurovascular examination • Related Structures - elbow

Introduction

• Introduce yourself, confirm patient ID • Explain examination, gain consent and uncover patient’s arm • Ask if they have had: - any problems with their wrists or hands - any pain or stiffness - restriction of daily activities • Does the patient hold their hands in normal posture? • Any splints to hand, elbow or wrist? • Gel hands

Look

With hands resting in pronation • Examine dorsum of hands and wrists, looking for: - Skin: scars, erythema, rash, gouty tophi - Nails: pitting, thickening / discolouration of psoriatic arthropathy - Muscles: wasting of dorsal interossei. Wasting of the first dorsal interosseous muscle in the first web space can be indicative of ulnar nerve entrapment/neuropathy - Joint deformities: ulnar/radial deviation of wrist, ulnar deviation of fingers (seen in rheumatoid arthritis), fixed flexion of finger proximal or distal interphalangeal joints - Swelling/ Lumps: Rheumatoid nodules, Heberden’s nodes (DIP), Bouchard’s nodes (PIP) Document Owner: Clinical Skills – LK/ST Last Updated: Nov 2019 With hands resting in supination • Examine palmar surfaces:

- Skin: as above, looking for scars from carpal tunnel release - Muscle: bulk of thenar and hypothenar eminences (compare to the other side). Thenar wasting can be seen in advanced carpal tunnel syndrome and hypothenar wasting can be seen in ulnar nerve entrapment - Swelling/lumps: Dupuytren’s cords can be seen/felt in the palm and flexor aspect of fingers - Joint deformities: Dupytren’s disease/trauma/inflammatory or osteo arthritis can cause joint contractures

With palms facing each other • Examine radial aspects - Joint deformities: tendon swelling over the first extensor compartment can be indicative of De Quervain’s tenosynovitis

With elbows flexed, showing ulnar borders and posterior of forearms • Examine ulnar aspects - Skin: elbow scars from ulnar nerve surgery, psoriatic rashes, lumps - Joint deformities: prominent ulnar styloid, rheumatoid nodules

Feel

• Assess temperature • Assess radial and ulnar pulses • Palpate for lumps, tenderness or swelling across the following:

Dorsal Side DORSAL VIEW

- Radial styloid - 1st extensor compartment (1cm proximal radial styloid): tenderness may be De Quervain’s tenosynovitis - Anatomical snuffbox: tenderness may be scaphoid pathology/fracture - Scaphoid-Lunate joint (distal to Lister’s tubercle) - Ulnar styloid - MCP, PIP and DIP joints of each digit Hamate Trapezoid Palmar side Pisiform Trapezium Triquetral Scaphoid Lunate Capitate - Pisiform and scaphoid ULNAR RADIUS

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Move

Active movements With hand suspended above the table, guide the patient through: • Pronation • Supination • Wrist extension • Wrist flexion

With hands resting on the table, pronated, guide the patient through: • Ulnar deviation • Radial deviation • Finger abduction (spread fingers) • Finger adduction (close fingers) • Thumb abduction (thumb away from index finger) • Thumb adduction (thumb towards from index finger) • Finger and thumb flexion (fist) • Finger and thumb flexion (open fist and stretch out)

With hands resting on the table, supinated: • Flexor Digitorium Profundus: stabilise the MCP and PIP of little finger, ask patient flex and extend DIP. Repeat each finger. Test against resistance • Flexor Digitorium Superficialis: ask patient to bring the tip of the little finger to the palm, as you stabilise the other fingers. Repeat each fingertip. Test against resistance • Opposition • Thumb extension, flexion, abduction, adduction

Source: http://boneandspine.com/muscles-of-hand-and-wrist/

Special Tests

Tinel’s test for carpel tunnel syndrome • With hand supinated, tap over the median nerve at the wrist/carpal tunnel • Tingling in thumb, index finger, middle finger and lateral half of ring finger = Positive test • Note other signs: wasting thenar eminence, weakness thumb abduction, impaired sensation over tips of thumb, index and middle fingers. Compare to other side.

Phalen’s test for carpel tunnel syndrome • Passively flex wrist and maintain position for 30s • Tingling in thumb, index finger, middle finger and lateral half of ring finger = positive test

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Tinel’s sign (cubital tunnel syndrome) • Applicable if there is any suspicion of ulnar nerve entrapment behind the medial epicondyle at the elbow (cubital tunnel syndrome). The ulnar nerve can be compressed as it passes between the two heads of the flexor carpi ulnaris • Gently tap with the tip of your index finger behind the medial epicondyle extending distally for about 3 cm • Ask if this causes pins and needles sensation in the distribution of the ulnar nerve

Finkelstein test for De Quervains tenosynovitis • Ask patient to make a fist with thumb tucked inside, dorsal side up. Passively deviate the wrist to the ulnar side. Pain over dorsum and radial aspect of the thumb = positive test

Neurological Examination

Sensory function • Check patient’s ability to comply with examination by asking them to close eyes and tell you when they feel you touch the sternum • With eyes closed ask them to say yes, as you touch each dermatome: • Radial Nerve - first web space • Median Nerve - tip index finger • Ulnar Nerve - little finger

Motor function • Radial Nerve Source: https://anatomywiki101.com - “Make a fist and cock your wrists back.” Assess resisted wrist extension - “Straighten your fingers, don’t let me bend them”. Assess resisted extension at the MCP (continuation of radial nerve = posterior interosseus nerve) • Median Nerve - “Lay your hand flat, palms up. Raise thumb to the ceiling, don’t let me push it down.” Assess resisted thumb abduction (abductor pollicis brevis) • Ulnar Nerve - “Stretch out your fingers, stop me from closing them.” Assess resisted finger abduction (dorsal interossei). - Perform Froment’s test by asking the patient to hold a sheet of paper between thumb and index finger and trying to pull it out. May also be assessed by asking the patient to hold the paper between two fingers.

Related Structures

• Elbow

Conclusion

• Thank patient, ask them to get dressed, report/record findings

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