Wrist & Hand

Orthopaedic AssessmentsLectures 23 & 24

The Wrist & The Wrist & HandHand

Agenda– Introduction– Applied anatomy– Patient History– Observation– Examination

• Active movements• Passive movements• Isometric

– Special tests

Wrist & Hand - Introduction

• Most active and intricate parts of the upper limb

• Vulnerable to injury• Respond poorly to severe trauma• Mobility is enhanced by

movements of the shoulder and elbow

Wrist & Hand - Introduction

• Functions– Communication– Protection– Motor and sensory organ

• Important to remember that when examining the hand/wrist, they do not work in isolation from the elbow and shoulder

Wrist & Hand – Applied Anatomy

• 29 bones• 19 intrinsic muscles• 20 extrinsic muscles• Many articulations

Triangular Cartilaginous Disc• O: ulnar side of distal

radius• I: ulna at styloid

process• Adds stability

– Close relation b/w ulna and carpal bones

– Stabilizes long bones


Distal Radioulnar Joint

• Resting Pos'n 10° of supination• Close Pack Pos'n 5° of supination• Capsular Pattern pain at extreme of

rotation


Radiocarpal (Wrist) Joint

• Resting Pos'n neutral with slight ulnar deviation

• Close Pack Pos'n extension• Capsular Pattern flexion and

extension equally limited


Radiocarpal (Wrist) Joint

• Radius articulates with the scaphoid and lunate

• Lunate and triquetrium articulate with the TFCC


Intercarpal Joints

• Resting Pos'n neutral or slight flexion

• Close Pack Pos'n extension• Capsular Pattern none


Intercarpal Joints

• Includes the joints of b/w the individual bones of the proximal row of carpal bones (scaphoid, lunate, triquetrium) and the joints b/w the individual bones of the distal row of carpal bones (trapezium, trapezoid, capitate, hamate)


Midcarpal Joints

• Resting Pos'n neutral or slight flexion with ulnar deviation

• Close Pack Pos'n extension with slight ulnar deviation

• Capsular Pattern equal limitation of flexion and extension


Midcarpal Joints

• Form a compound articulation b/w the proximal and distal rows of carpal bones– ie. Grouping of bones

• MEDIALLY: scaphoid, lunate & triquetrium articulate with capitate & hamate

• LATERALLY: scaphoid articulates with trapezoid and trapezium

MEDIAL GROUP LATERAL

GROUP


Carpometacarpal Joints (THUMB)

• Resting Pos'n midway b/w abduction and adduction, and midway b/w flexion and extension

• Close Pack Pos'n full opposition

• Capsular Pattern abduction, then extension


Carpometacarpal Joints (FINGERS)

• Resting Pos'n midway b/w flexion and extension

• Close Pack Pos'n full flexion• Capsular Pattern equal limitation in all

` directions


Carpometacarpal Joints

• Fingers 2-5, only gliding movements are allowed for

• At the thumb, movement into 6 directions are allowed for:– Flexion, extension, abduction,

adduction, rotation and circumduction


Metacarpophalangeal Joints

• Resting Pos'n slight flexion• Close Pack Pos'n THUMB: full

opposition FINGERS: full flexion

• Capsular Pattern flexion, then extension


Metacarpophalangeal Joints

• 2nd & 3rd metacarpophalangeal joints are generally immobile and are the primary stabilizing factor of the hand


Interphalangeal Joints

• Resting Pos'n slight flexion• Close Pack Pos'n full flexion• Capsular Pattern flexion, then

extension


• During flexion of the fingers, they converge towards the scaphoid tubercle– “cascade sign”

Wrist & Hand – Patient History

•Review relevant section in Magee

Wrist & Hand – Patient Observation

• Views from palmar and dorsal aspect• Normal bony and soft tissue contours

–Include forearm• Willingness to move or ability to move

hand• Finger flexion – normally when fingers

and wrist are at rest in neutral, the fingers become more progressively flexed as you move from the radial to ulnar side


• Ulcerations: neurological or circulatory problems–Look for alteration in colour of

limb; may indicate circulatory problem

• Wounds / scarring – may interfere with finger mobility and control


• Nails: –“clubbed” nails may point to

cardiac or respiratory dysfunction–“spoon-shaped” nails are often

the result of fungal infection, anemia, iron deficiency, chronic diabetes, local injury, psoriasis, developmental abnormality, chemical irritation


• Duputryen's Contracture

• the connective tissue under the skin of your palm contracts and toughens (thickens) over time


• Ganglions & Cysts– Benign, fluid-filled

capsules– Occur adjacent to

joints and tendons– Cause: unknown

• One school of thought is FRICTION

– Not cancerous, nor will they spread


• Thenar / Hypothenar Atrophy– Thenar: median n.– Hypothenar: ulnar n.– First dorsal interosseous muscle: C7 nerve root


• Osteoarthritis–Aka: degenerative arthritis–Abnormal wearing of cartilage of

joints–Loss of synovial fluid–Heberden's Nodes: bony nodes at

the DIP (dorsal surface)• Early sign of OA


• Rheumatoid Arthritis–Chronic, systemic autoimmune

disorder that causes the immune system to attack one's own joints

–Can be very disabling and painful–Problems with other organs of the

body can occur– Bouchard's Nodes: bony nodes at the

PIPs– Ulnar drift


• Boutonniere Deformity–Extension of the

metacarpophalangeal and DIP joints, flexion of the PIP joint

–Rupture of the extensor tendon over joint•Trauma, RA


• Swan-Neck Deformity–Flexion of the

metacarpophalangeal and DIP joints, extension at the PIP

–Usually due to contracture of the intrinsic muscles•Trauma, RA

Wrist & Hand – Patient Observation• Claw Fingers

–Loss of intrinsic muscle action and the overaction of extrinsic (long) extensor muscles on the proximal phalanx of the fingers

–MCP joints are hyperextended; PIPs and DIPs are flexed

–Normal cupping of hand is lost–Combination of median and ulnar

nerve palsy


• Trigger Finger–Thickening of the flexor tendon sheath

causing sticking of the tendon when the patient attempts to flex the finger

–Inflammation leads to swelling and tendon stenosis

–Finger will snap


• Ape Hand Deformity–Median nerve palsy causing atrophy of

the thenar eminence–Thumb falls in line with the fingers as a

result of the pull of the extensor muscles

–Person unable to oppose or flex the thumb


• Drop-Wrist Deformity–Radial nerve palsy leading to inability

of extensor muscles to function• Wrist and fingers cannot be extended


• Mallet Finger Deformity–Rupture or avulsion of the extensor

tendon where it inserts into the distal phalanx of the finger

–Distal phalanx rests in a flexed position


• Raynaud's Disease–Cold, painful hands–Idiopathic vascular disorder

characterized by attacks of pallor and cyanosis of the extremities often brought about by cold or emotion

EXAMINATIONEXAMINATION

Wrist & Hand – Examination

• Wrist and hand have both a fixed and a mobile segment

• Fixed Segment: distal row of carpal bones (trapezium, trapezoid, capitate, hamate) and the 2nd and 3rd MC bones– Provides stability to the hand and wrist without

sacrificing mobility– Not a rigid segment; there is movement, but less

so then the mobile segment• Mobile Segment: five phalanges and the 1st,

4th and 5th MC bones

FIXED SEGMENT ofWRIST AND HAND


ACTIVE ROM• Pronation (forearm) 80° - 90°• Supination (forearm) 90°• Wrist abduction 15°

–Radial deviation• Wrist adduction 30° - 45°

–Ulnar deviation• Wrist flexion 80° - 90°• Wrist extension 70° - 90°


ACTIVE ROM (cont'd)• Finger flexion

–MCP 85° - 90°–PIP 100°–DIP 80° - 90°

• Finger extension–MCP 30° - 45°–PIP 0°–DIP 20°


ACTIVE ROM (cont'd)• Finger abduction 20° - 30°• Finger adduction 0°• Thumb flexion

–CMC 45° - 50°–MCP 50° - 55°–IP 85° - 90°

• Thumb extension–MCP 0°–IP 0° - 5°


ACTIVE ROM (cont'd)• Thumb abduction 60° - 70°• Thumb adduction 30°• Opposition of the thumb and 5th digit (tip-

to-tip)• Combined movements (if necessary)• Repetitive movements (if necessary)• Sustained movements (if necessary)


THUMB ABDUCTION & ADDUCTION

THUMB FLEXION & EXTENSION


PASSIVE ROM• Pronation tissue stretch• Supination tissue stretch• Radial deviation bone-to-bone• Ulnar deviation bone-to-bone• Wrist flexion tissue stretch• Wrist extension tissue stretch• Finger flexion tissue stretch• Finger extension tissue stretch


PASSIVE ROM (cont'd)• Finger abduction tissue stretch• Thumb flexion tissue stretch• Thumb extension tissue stretch• Thumb abduction tissue stretch• Thumb adduction tissue approximat'n• Opposition tissue stretch


ISOMETRIC RESISTED ROM• Pronation• Supination• Radial deviation• Ulnar deviation• Wrist flexion• Wrist extension• Finger flexion• Finger extension


ISOMETRIC RESISTED ROM (cont'd)• Finger abduction• Finger adduction• Thumb flexion• Thumb extension• Thumb abduction• Thumb adduction• Opposition


FUCTIONAL

• Thumb is the most important digit–Relation to other digits, forces it can

bear, mobility• Index finger is the second most

important digit–Musculature, strength, interaction with

the thumb


FUCTIONAL

• Middle (3rd) finger – strongest–Important for power and precision

• Little (5th) finger – enhances power grip, affects the capacity of the hand, holds objects against the hypothenar eminence

• Ring (4th) finger – least functional of the fingers


FUCTIONAL

• In terms of loss:– Thumb: 40-50% of hand function– Index finger: 20% of hand function– Middle finger: 20% of hand function– Ring finger: 10% of hand function– Little finger: 10% of hand function


FUCTIONAL

• In terms of loss:– The entire hand: 90% loss of upper limb function!!!


FUCTIONAL - GRIP

• Power Grip–Primary function of the ulnar side of hand –Used whenever strength or force is the

primary consideration• Precision Grip

–Limited mainly to the MCP joints and involves primarily the radial side of the hand

–Accuracy and precision

Wrist & Hand – Special Tests

SPECIAL TESTS• Tendons & Muscles

– Finkelstein's Test– Bunnel-Littler Test

• Neurological– Tinel's Sign at the

wrist– Phalen's Test– Reverse Phalen's

Test– Froment's

– Circulatory• Allen's Test

– Instability Tests (ligamentous)• Shuck Test• Thumb Ulnar

Collateral Ligament instability Test

– Other• Murphy's Sign

(Skyline Sign)


FINKELSTEIN TEST(1) Client: makes fist with thumb in fist(2) Therapist: stabilizes the forearm and ulnar deviates

the wrist

POSITIVE: pain over abductor pollicis longus and extensor brevis tendons

INDICATES: de Quervain's tenosynovitis in the thumb

* can cause discomfort in normal individuals, so compare bilaterally and consider whether the client's symptoms are reproduced


BUNNEL-LITTLER TEST(1) Therapist: holds MCP of test finger in

slight extension(2) Therapist: moves PIP (of same finger)

into flexion

POSITIVE: inability to flex the PIPINDICATES: tight intrinsic muscles or

contracture of the joint capsule (ie. arthritide)


TINEL'S SIGN (at the wrist)(1) Therapist: tap over the carpal tunnel at

the wrist

POSITIVE: tingling or paraesthesia into the thumb, index finger, middle and lateral half of ring finger (median nerve distribution)

INDICATES: carpal tunnel syndrome


PHALEN'S TEST(1) Client or Therapist: maximally flex

wrists and hold them together for 1 minute

POSITIVE: tingling or paraesthesia in the median nerve distribution



REVERSE PHALEN'S TEST(1) Client or Therapist: maximally extend wrists

and hold them together(2) Therapist: apply direct pressure over the

carpal tunnel for 1 minute

POSITIVE: tingling or paraesthesia in the median nerve distribution



FROMENT'S SIGN(1) Client: attempts to grasp a piece of paper b/

w the thumb and index finger(2) Therapist: pull paper away

POSITIVE: (a) terminal phalanx of thumb flexes; (b) MCP joint of thumb hyperextends

INDICATES: (a) paralysis of abductor pollicis muscle; (b) Jeanne's Sign– Both positives are indicative of median

nerve paralysis

Wrist & Hand – Special TestsALLEN'S TEST(1) Client: ask to open and close the hand several

times as quickly as possible and then squeeze the hand tightly

(2) Therapist: compress the radial and ulnar arteries by placing thumb and index finger over them

(3) Client: open hand(4) Therapist: release pressure over one artery then

the other

POSITIVE: -----INDICATES: patency of the radial and ulnar arteries

and determines which artery provides the major blood supply to the hand


SHUCK TEST(1) Therapist: hold client's wrist in flexion(2) Therapist: resist isometric extension of

the fingers

POSITIVE: pain (dorsum of wrist)INDICATES: scaphoid, radiocarpal OR

midcarpal instability/inflammation


THUMB ULNAR COLLATERAL LIGAMENT INSTABILITY TEST

(1) Therapist: stabilize client's hand and take thumb into extension with the other

(2) while holding the thumb in extension, apply a valgus stress to the MCP joint of thumb

POSITIVE: valgus movement greater than 35°INDICATES: damage to ulnar collateral ligament (and

collateral ligaments); Gamekeeper's thumb; Skier's thumb


MURPHY'S SIGN (SKYLINE SIGN)(1) Client: make a fist and hold arm

straight out

POSITIVE: head of 3rd MC is level with that of 2nd and 4th MC

INDICATES: dislocation of the lunate

Wrist & Hand

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