Wrist and Hand 201wrist and Hand Eval 4

MODULE: PHYSIOTHERAPY SCIENCE 272 SUB-MODULE: EVALUATION THEME: JOINTS
Wrist and hand

2014
Division of Physiotherapy, Department of Interdisciplinary Science, Faculty of Health Science, Stellenbosch University. 2012. All rights reserved.
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.
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
Bones of the Wrist & Hand

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
Joints 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.
Joint surfaces 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)
Arthrokinematic mvts of the Wrist flex/ext

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).
Observation
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.
Formal observation
General Posture Pts 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 pts problem. Swelling/joint effusion
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
Common deformities: Swan-neck deformity PIPJ hyperext, DIPJ fexed Boutonnire 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 Herbedens nodes - osteoarthritis Bouchards nodes - Rheumatoid arthritis Club nails - respiratory/cardiac disorders
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
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
Functional/Reproducing movement
Problematic movement E.g. Coming hair/holding cup/power grip/spherical grip/precision grip Weight-bearing vs traction activities
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
Passive Physiological mvts: Hand placements

Movement & Endfeel Flexion (firm ) Extension (firm/hard) Radial Deviation (hard/firm) Ulnar Deviation (firm) Flexion of fingers (firm/hard) Extension of the fingers (firm/hard) Abduction of fingers(firm) Adduction of fingers (firm) Execution Grab wrist & hand by both hands R hand supports forearm, L hand takes wrist into extension R hand supports just proximal to wrist joint, while L hand moves wrist A/A R hand supports carpus A/A Stabilize carpus, use index finger and thumb for mvt 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
Close-packed position
Position in which the joint surfaces are Wrist 80-85 70-80 20-25 30-35 maximally congruent an the ligaments MPand capsule 90 are 30-45 20 Full maximally taut. E.g. PIP 100of IP 0 extension joints
DIP Thumb MP Thumb IP 90 50 90 0 50 20 70 0 Flex. Ext. R.D U.D Abd Add
Goniometry
Wrist Flexion Wrist Extension Triquetrum (lat midline ulna) Olecranon & Ulnar styloid process (lat midline) 5th metacarpal Midpoint Proximal reference point Distal reference point Triquetrum OR Capitate (lat midline ulna) Olecranon & Ulnar styloid process Or midline of forearm (lat midline) 5th metacarpal OR midline 3rd metacarpal
Radial Deviation
Ulnar Deviation
(middle of dorsal aspect of wrist) Capitate Lateral epicondyle of the humerus
Midpoint
(middle of dorsal aspect of wrist) Capitate Lateral epicondyle of the humerus
Proximal reference point
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 Extensor carpi radialis longus, Extensor carpi radialis brevis, Extensor carpi ulnaris Pronator teres, pronator quadratus Supinator Abductor pollicis longus, Extensor pollicis brevis
Extension
Pronation Supination Radial deviation
Ulnar Deviation
Flexor carpi ulnaris, Extensor carpi ulnaris

Fingers Flexion Flexor digitorum superficialis, profundus, lumbricals; Flexor digiti minimi, Adductor digiti minimi Extensor digitorum, lumbricals
Extension
Abduction Adduction Thumb Flexion Thumb Extension Thumb Abduction Thumb Adduction Thumb opposition
Interosseous (dorsal), Abductor digiti minimi Interosseous (palmar) Flexor pollicis brevis, Extensor pollicis brevis, Extensor pollicis longus, Abductor pollicis longus Abductor pollicis longus Adductor pollicis Opponens pollicis
Division of Physiotherapy, Department of
Interdisciplinary Science, Faculty of Health Science, Stellenbosch University. 2012. All rights
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
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 pts hand anteriorly and posteriorly
med & lat transverse Hands grasp around the distal radius and ulna and proximal end of the metacarpals. Right hand glides the pts hand medially and laterally
caudad Grasp around the distal radius and ulna and the proximal end of the metacarpals. Right hand: pull the hand away from the wrist.
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.
Intercarpal joint & Apply pressure with your thumb to the anterior or posterior aspect of each carpal bone.
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.
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
Special Tests
Differentiation tests Joint integrity tests Sweater finger sign test Carpal tunnel syndrome (Phalens test) De Quervains disease (Finkelstein test) Linburgs sign (tendonitis) Allen test (artery patency test) Thoracic outlet syndrome Hand volume test
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 Watsons scaphoid shift test Lunotriquetral bollottement test Midcarpal test
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
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 pts pain indicates instability of the scaphoid.
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
Sweater finger test

Loss of distal IPJ flexion when making a fist Ruptured flexor digitorum profundus tendon
Tinels 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
Carpal tunnel syndrome (Phalens test)

Median nerve test 1 minute sustained bilateral wrist flexion Paraesthesia production along the median nerve indicates a positive test Reverse Phalens test: pt makes fist with wrist in extension, PT applied pressure for 1 minute
De Quervains disease (Finkelstein test)

Pt makes fist with thumb inside the fingers passive ulnar deviation of wrist by PT Reproduction of symptoms: indicative of de Quervains disease (tedosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons)
Linburgs 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
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
Hand volume test

To measure swelling of hand Difference of 30 to 50ml between hand measurements = significant hand swelling Tape measure Compare sides

Wrist and Hand 201wrist and Hand Eval 4

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MODULE: PHYSIOTHERAPY SCIENCE 272 SUB-MODULE: EVALUATION THEME: JOINTS

Wrist and hand

Basic Anatomy (revision)

Bones of the Wrist & Hand

Joints of the Wrist & Hand

Joint surfaces of the Wrist & Hand

Arthrokinematic mvts of the Wrist flex/ext

Active Physiological movements

Passive Physiological mvts: Hand placements

(middle of dorsal aspect of wrist) Capitate Lateral epicondyle of the humerus

(middle of dorsal aspect of wrist) Capitate Lateral epicondyle of the humerus

Proximal reference point

3rd metacarpal Not 3rd phalanx

Distal reference point

3rd metacarpal Not 3rd phalanx

Isometric muscle tests

Pronation Supination Radial deviation

Flexor carpi ulnaris, Extensor carpi ulnaris

Passive accessory movements

Joint integrity tests

Ligamentous instability test

Watsons scaphoid shift test

Lunotriquetral bollottement test

Sweater finger test

Carpal tunnel syndrome (Phalens test)

De Quervains disease (Finkelstein test)

Linburgs sign (tendonitis)

Allen test (artery patency test)

Hand volume test

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