Tips on upper limb assessment

Mr V Rajaratnam FRCS(Ed),Dip Hand Surgery (Eur)

Consultant Hand Surgeon
EXAMINING THE HAND
• Systems of examination.
• History.
• Normal - abnormal positions and movements
of the hand.
• Special conditions and tests.
• Radiological Evaluation.
• Arthroscopy - Electrodiagnosis.
 HISTORY
IMPORTANT QUESTIONS IN ALL CASES:
•Social history (very important especially when considering operation) -
professional - recreational activities.
• Dominant hand.
• Function of the whole upper limb - functional state of the opposite
limb.
• General health, known pathologies, current therapy
(diabetes, rheumatoid arthritis, corticosteroid intake...)
• psychological state, known allergies.
• Smoking - alchohol intake.
• Family history.
 HISTORY
PERSONALITY - INTELLIGENCE AND RELIABILITY

• Meeting the surgeon’s gaze.

• Honesty of the patient.
• Innapropriate affect: ill defined pain.
• Malingering: Glove hypaesthesia, rapid echange grip
strength, distracted function.
•Liability: the patient wishes to extract maximum compensation.

• After taking full history most of the surgeons have concluded to d/d of
only a few pathological conditions.
 NORMAL POSITIONS OF THE HAND
•All fingers when flexed at the MCPJ and
the PIPJ point to the tubercle of the
scaphoid.
•Very important in assessing the normal
rotation in fractures of the metacarpals
and phalanges.
•In rotation malalignement the
«scissoring» deformity is
unacceptable, both cosmetically and
functionally.
•Observing the plane of the fingernails
helps detecting any malrotation in case
of fracture - always compare with the
other limb.
BASIC POSITIONS OF THE HAND

• Precision pinch: The tips of fingernails

of index finger and thumb are brought
together.
• Pulp pinch: The pulps of index finger
and thumb are opposed. Normal power
5 - 10 pounds.
•Key pinch: The pulp of the thumb is
opposed to the radial side of the middle
phalanx of the index finger. Normal
power 13 - 20 pounds.
•Chuck grip: The digital pulps of index
and middle fingers brought into contact
with the pulp of the thumb.
 BASIC POSITIONS OF THE HAND
• Hook grip: The fingers are flexed in the
IPJ and extended in the MCPJ.
•Span grasp: From the hook grip the IPJ
are extended 30° and the thumb
abducted fully.
•Power grasp: The fingers flexed fully
and the opposed thumb is flexed over
the fingers to increase power. Normal 90
- 100 pounds. The normal variation is
10%, but sometimes the dominant hand
is not always stronger.
•Flat hand: Fingers, thumb
extended, thumb adducted.
 MUSCLE STRENGTH TESTING
• The Jamar grip stength dynamometer. The combined
efforts of the intrinsic and the extrinsic muscles are
evaluated in Levels 1, 2 and 3. In Levels 4, 5 primary
extrinsic muscle is evaluated.
•The pinch meter. The pinch meter should be held lightly
by the examiner and never fixed in any way during testing.
• SCALE OF POWER:
0: Total paralysis - no contraction detectable on
palpation.
1: Flicker - no movement, but contraction palpable.
2: Movement with gravity eliminated - placing the line
of action of the muscle in the horizontal plane.
3: Movement against gravity.
4: Movement against gravity and resistance.
5: Full power.
 EXAMINING THE HAND
RANGE OF MOTION
• Perform full ROM active and passive in all
the fingers in both hands.
• Normal: MCPJ: 0 - 90°
PIPJ: 0 - 120°
DIPJ: 0 - 60°
Thumb IPJ: 0 - 60°.
• It is not possible to flex the DIPJ of 3 - 4 -
5 fingers independently.
It is very important when the fingers flex
, their pulp to touch the palm.
 EXAMINING THE HAND RANGE OF
MOTION - THE THUMB
• The 1st MCPJ (trapeziometacarpal) is functionally the
most important because it allows movement of the
whole column of the thumb.
• There is confusion in terminology - different authors
use different terms to describe thumb movements.
• ABDUCTION: Seperation in the plane of the palm.
• ANTEPOSITION: Seperation in a perpendicular plane
to the plane of the palm.
• ADDUCTION: Brings the thumb in contact with the
palm
• OPPOSITION: Complex movement: Anteposition and
adduction of the 1st metacarpal, flexion of the MCPJ
and IPJ, pronation of all the skeletal elements..
 EXAMINING THE WRIST
RANGE OF MOTION
• Perform full ROM active and passive in
both hands.
• Normal: Extension: 60°
Flexion: 70°
Wrist radial deviation: 20°
Wrist ulnar deviation: 30°
Forearm supination: 80°
Forearm pronation: 80°
 EXAMINING THE WRIST
DORSAL PALPATION
• Scaphoid: just distal to the radial styloid. Its
tuberosity prominent in extension - radial
deviation. The waist palpable deep to the
anatomic snuffbox (always examine both
hands).
• Trapezium: distal to the scaphoid, along the axis
of the thumb. Can be distinguished from the 1st
metacarpal by gently rotating the thumb.
• Lunate: Prominent with the wrist flexed, ulnar
to the Lister’s tubercle.
• Capitate: distal to the lunate.
• Hamate: proximal to the 5th metacarpal.
• Distal radioulnar joint: radial to the ulnar head.
• Triangular Fibrocartilage Complex: distal to the
radioulnar joint.
 EXAMINING THE WRIST
VOLAR PALPATION
• Scaphoid tuberosity: Distal to the radial
styloid, most prominent in radial deviation.
• Trapezium: distally to the scaphoid, in the
axis of the index finger.
• Pisiform: bony prominence in the base of
the hypothenal eminence
• Hook of hamate: radially and distally to the
pisiform.
• Palmaris longus: present in 85%. Flexion of
the wrist while opposing the thumb and
little finger.
 TENDON EXAMINATION - PASSIVE MOTION

• In non - cooperative patient, sedated or in

children.
• Firm pression in the ulnar - anterior
aspect of middle - distal third of forearm.
• Intact tendons: 1 - 2 cm flexion especially
in the ulnar 3 fingers.
• For the FPL: Pressure on the distal -
anterior radius: flexion of the IPJ of the
thumb.
 NERVE EXAMINATION
SENSORY DISTRIBUTION
• Sensory skin territories have ill defined boundaries and
adjacent territories overlap extensively.
• Sheddon’s classification of nerve injury:
- Neuroapraxia: selective demyelinization of large fibres in
the nerve with no axonal degeneration.
- Axonotmesis: The axons are severed but the anatomical
continuity of the nerve is preserved: the Schwann cells
which form the sheath are uninterrupted.
- Neurotmesis: Loss of continuity of the nerve.
• Sudderland’s classification of nerve injury:
I: Neuroapraxia.
II: Axon severed - endoneurial tube intact.
III: Endoneurial tube torn.
IV: Only epineurium intact.
V: Loss of continuity.
VI: Combination of above.
 NERVE EXAMINATION
AUTONOMOUS ZONE
In total recent nerve division the area of
absolute sensory loss:
• Ulnar nerve: palmar aspect of small finger.
• Median nerve: palmar aspect of index
finger.
• Radial nerve: dorsum of MPJ of the
thumb.
• C5 Root: over the belly of the deltoid.
• C6 Root: the thenar eminence.
• C7 Root: NIL.
• C8 Root: ulnar border of the hand.
• T1 Root: ulnar border of the elbow.
• T2 Root: inner aspect of the arm.
 NERVE EXAMINATION
TWO POINT DISCRIMINATION
• Determines the minimal distance at which a
patient can discriminate between being
touched with one or two points.
• Patient’s vision is blocked.
• Distance of 5mm between points.
• One or two points toutched in the center of
the finger tip.
• The instrument should be applied lightly.
• Ten separate stimuli are given. If correct
answers <7, distance increased.
• Interpretation: Normal: <6 mm, Fair: 6 - 10
mm
Poor: 11 - 15 mm, Protective: one point
perceived, Anesthetic: no point perceived.
 NERVE EXAMINATION
TINEL’S TEST
• Percutanous percussion of the nerve trunk with
the tip of the finger.
• Often positive in the site of nerve compression
(carpal tunnel, cubital tunnel), or a little proximal
to it, producing paraesthesia, radiating into the
sensory distribution of the nerve.
• The first detectable clinical sign of recovery -
neural regeneration.
• The «pins and needles» sensation is caused be
regeneration of the sensory axons which are very
sensitive to pressure.
• It is absent in the early stages - appears 4 -6
weeks after the injury. May be difficult to elicit if
the nerve lies deep to a large mass of muscle.
• Should be interpreted only in conjunction with
other clinical findings.
 RECOVERY AFTER NERVE INJURY

• Scale for the sensibility assessment (BMRC, Sheddon 1975):

S0: Absence of sensibility in the autonomous area.
S1: Recovery of deep cutaneous pain sensibility.
S2: Return of some degree of superficial cutaneous pain
and tacttile sensibility.
S3: Return of superficial cutaneous pain and tactile
sensibility with dissappearance of over - response.
S3+: As in stage 3 with some recovery of the 2PD.
S4: Complete recovery.
 NERVE EXAMINATION
TACTILE ADHERENCE TEST
• Sweating is lost in the distribution of a
divided peripheral nerve.
• The digit in the denervated area is
smooth and dry.
• The smooth surface of a pen is passed
gently but firmly back and forward in
each side of the finger.
• In the presence of sweat, adhesion is
shown by a slight moving of the finger.
• An insensate pulp with no sweating will
show no motion
 NERVE EXAMINATION
PARALYSIS
• Ulnar Nerve: FLEXOR DIGITI QUINTI
• Median Nerve: ABDUCTOR POLLICIS
BREVIS
• Radial nerve: WRIST EXTENSORS
• The inability to initiate movement is not
an absolute evidence that the muscle or
the nerve is damaged. Pain or even
nervousness can inhibit motion.
• The best way to examine a muscle is to
place the limb in the position which the
muscle normally produces, and instuct:
“ Keep it there, don’t let me move it”.
 NERVE EXAMINATION
MUSCLE WAISTING
• Paralysed muscles become increasingly
atrophic. Most noticeable:
- Abductor Pollicis Brevis: Median Nerve.
- Abductor Digiti Quinti and 1st Dorsal
Interosseous: Ulnar Nerve.
• The deformity has two components:
- Depression due to loss of muscle bulk,
- Prominence of bones usually masked by
muscle.
 REFLEXES TESTING
• Absent: Lower motor neuron
disorders (division of motor
nerve).
• Exaggerated: Upper motor
neuron injury (CVA and cord
transection)
• Biceps tendon: C5 nerve.
• Brachioradialis: C6 nerve
• Triceps tendon: C7 nerve.
 VASCULAR EVALUATION
In case of injury
• Diminution or absence of distance Pulses.
• Pallor - especially in the nailbeds.
• Pain - most evident when handling the limb.
• Paraesthesia - hypaesthesia - anaesthesia.
• Paralysis - established compartment syndrome.
• Cold - any temperature below 30°.
In chronic cases:
• Intermittent claudication.
• Persistent ulceration.
• Cold intolerance.
• Colour change.
• Stiffness of the joints.
 VASCULAR EVALUATION
• Assessment of color - temperature (in
comparison to the unaffected fingers) -
capillary refil.
• Squeeze the fingrtip: after blanching refil>
2 sec or incomplete: arterial insufficiency
suspected.
• Extremely brisk capillary refil with dark
blue coloration: venous insufficiency.
• Futher assessment with fingertip puncture
with steril 20 - gauze needle (in the
anesthetised patient: bright red blood: no
isufficiency, slowly flowing dark venous
blood: arterial insufficiency, copious
amounts of dark blood: venous
insufficiency.
 VASCULAR EVALUATION
ALLEN’S TEST
• Determines the patency of both the radial
and the ulnar arteries.
• The hand exsanguinated by digital
pressure of both arteries and the patient
making strong fist.
• Pressure is released from the radial artery
- patent return of color and capillary refil
to the entire hand indicates patent radial
artery and palmar arch.
• Repeat step A and release the ulnar
artery.
• Normal filling time: <5 sec.
• Similar test with the digital arteries of the
finger: The digital Allen’s test.
 VASCULAR EVALUATION
RAYNAUD’S DISEASE
• Small vessel spasm of unknown cause.
• Cyclical colour and temperature changes in the digits.
• Sudden onset of symmetrical - bilateral extreme
pallor followed by cold pale cyanosis.
• Raynaud’s phenomemon involves the same
symptoms, with known underlying disorder
(scleroderma, polyarteritis
nodosa, SLE, RA, thrombangiitis obliterans etc.)
SPECIAL TESTS AND CONDITIONS
 FINKELSTEIN TEST
• Diagnostic in Stenosing tenosynovitis at the radial
styloid (De Quervain’s Disease).
• First dorsal compartment: Abductor Pollicis
Longus, Extensor Pollicis Brevis. The synovium of the
first compartment is particular prone to become
inflamed.
• The patient grasps the thumb firmly in the palm of his
hand.
• The examiner deviates abruptly the hand in ulnar
deviation, placing maximum strength to the
tendons, and producind severe pain.
• Finkelsein manoeuvre is not comfortable even in the
healthy hand - comparison.
• May be positive in arthritis (precise localization of
tenderness).
• Radial sensory nerve neuritis (Wartenberg’s
syndrome) may also produce falsely positive test - the
same pain with the thumb excluded, during ulnar
deviation.
 WATSON’S TEST
(SCAPHOID SHIFT TEST)
• Scaphoid instability.
• The thumb of one hand in the palmar
aspect of the scaphoid and the index
finger on the radial tubercle dorsally
(wrist in ulnar deviation).
• Maintaining firm pressure push the hand
strongly in radial deviation.
• If the ligaments of the proximal part of
the scaphoid are lax or torn, the
proximal pole will jump over the dorsal
lip of the radius with a «clunk».
 LICHTMAN TEST

• Ulnar midcarpal instability .

• The wrist pronated and palmar flexed.
• Radially deviation of the wrist: observe the
prominence of the triquetrum bone, 2cm distal to
the ulnar head.
• With ulnar deviation of the wrist it should
disappear.
• If it initially becomes more prominent and then
vanishes with a palpable «clunk», ulnar midcarpal
instability is present.
 GRIND TEST OF THE
TRAPEZIOMETACARPAL JOINT
• Stabilize the hand - place the middle
finger on the TMJ.
• Grasp the thumb and push it towards
the trapezium rotating it several times.
• A gritting or grinding sensation of bone
on bone felt by both the patient and
doctor an pain: positive sign: TMJ
arthritis.
 RADIOCARPAL AP DRAWER TEST
BALLOTMENT’S TEST

• Demonstrate abnormal movements

between adjacent bones by exerting
pressure in opposite directions.
• Radiocarpal drawer: Anteroposterior
force is applied and a drawer is elicited
in the radiocarpal joint.
• LT Ballotment’s test: Instability of the
lunotriquetral joint
• Volar pressure on lunate and dorsal on
the triquetrum. If there is any ligament
damage, painful shearing of the joint
will be produced.
 CARPAL TUNNEL SYNDROME
PHALEN’S TEST
• Placing the wrists in maximum flexion, both hands
in one time with the elbow extended (the normal
hand acts as a control).
• Onset of numbness - tingling in the median nerve
distribution in less than 60 seconds is considered
diagnostic for carpal syndrome.
• Reversed Phalen’s test: Placing the palms of the
hands together, raising the elbow as high as
possible. Ocassionaly positive when the Phalen’s
test is negative.
 CARPAL TUNNEL SYNDROME
CARPAL COMPRESSION - TINEL’S TEST
• Pressure over the median
nerve, immediately above the carpal
tunnel produces parestaesias - tingling in
the distribution of the medial nerve in
carpal tunnel syndrome.
• Very helpful in patients whose wrists
cannot be flexed (rheumatoid or
posttraumatic wrist arthritis).
• Percussion over the carpal tunnel
produces paresthesia in the distribution
of the median nerve: TINEL’S test.
CARPAL TUNNEL SYNDROME
APB MUSCLE STRENGTH TEST
• Hand on the table - palm up and the
patient brings the thumb up to 90° to the
palm.
• If muscle stengh impaired in
CTS, consider additional procedure
(Camitz procedure...).

• D/D from pronator syndrome

(compression of the median nerve
between the 2 heads of PT): No nocturnal
complaints - Dysaesthesia in the
palmar triangle (palmar cutaneous
branch of median nerve).
 CUBITAL TUNNEL SYNDROME
• Compression of the ulnar nerve in the
cubital tunnel.
• Paraesthesia - numbness in ring - small
fingers, hypothenar eminence and ulnar
half of the dorsum of the hand (d/d from
compression in the Guyon’s canal).
• Tinel’s sign positive over the ulnar nerve
in the cubital tunnel.
• Elbow flexion test: reproduces pain and
paraesthesia (similar to Phalens test).
• Weakness in the ulnar innervated
muscles in the hand - waisting of the first
web space.
 RADIAL TUNNEL SYNDROME
POSTERIOR INTEROSSEOUS NERVE SYNDROME
• Compression of radial nerve in:
- radiohumeral joint.
- ECRB muscle.
- Radial reccurent fan vessels.
- Arcade of Froshe (supinator muscle).
• No sensory symptoms or motor loss in RTS.
• Tenderness over the extensor tendons distally to the elbow -
resembling lateral epicondylitis (tennis elbow).
• MIDDLE FINGER TEST: Resisted finger extension elicits greater
pain in the extension of the middle finger (ECRB muscle
inserts in the base of 3rd metacarpal).
• PINS: Pain - weakness - paralysis of the muscles supplied by
the posterior interosseous nerve.
THORACIC OUTLET SYNDROME
(TOS)
• Variations and combinations of neurologic and vascular symptoms affecting the
upper limb.
• Abnormal compression and irritation of the brachial plexus and suclavian artery.
• Conditions congenital or aquired, can appear in one or several levels most
probable in the thoracic outlet.
• Below: first rib. Anteriorly: scalenous anterior. Behind: scalenous medius.
• Cervical rib, rudimentary first rib (usually innocent), fibromuscular, tendinous or
ligamentous bands, swelling, trauma, postular changes (the military brace
position).
THREE - MINUTE ELEVATED ARM EXERCISE TEST, IN THE
«SURRENDER» POSITION
ROOS TEST
• The most reliable in the diagnosis of thoracic outlet
syndrome.
• Arms abducted, elbow flexed.
• Opens and closes his hands, keeping shoulders
backwards.
• Normal extremity: mild fatique.
• Neurologic TOS: Early tingling in the fingers - hands -
forarm, arm heavy, aches.
• Venous TOS: Arm cyanotic from proximally to
distally, and wrist veins become distended.
• Arterial type: The pulse may be occluded, arm and
hand become ischaemic, white, the muscles fail, the
arm drops
 LATERAL EPICONDYLITIS
(TENNIS ELBOW)
• Passive wrist flexion (pain in the
common extensor origin).
• Resisted wrist extension (pain in the
common extensor origin).
• Resisted extension of the middle
finger (D/D from radial tunnel
syndrome - pain proximal to the
common extensor origin).
 DUPUYTREN’S DISEASE
• Contracture of the palmar fascia.
• Familiar disorder - common in
diabetics, smokers, patients using
antiepileptic medication.
• Commences with apainful palm
nodule, progresses in the development of
bands (affect (order of frequency):
ring, small, middle, thumb, index fingers).
• Grading (Woodruff, Waldram).
- 1: Nodule - no contracture.
- 2: MCP contracture only.
- 3: MCP and PIP contracture.
- 4: As with 3 with two fingers.
- 5: Finger stuck in the palm.
• Examine the dorsum of the PIPJ for Garrod’s
knuckle pads.
 PATHOGNOMONIC POSTURES
• Cerebral palsy.
• Brachial Plexus injuries.
• Radial nerve .
• Ulnar nerve .
• Median nerve.
 CEREBRAL PALSY
• This differs from all other nerve
lesions - apart from a cerebrovascular
accident - in that it is an upper
neuron injury, and there is a great
degree of spasticity.
• Extrinsic postural change: Flexion of
elbow, wrist, fingers - pronation of
forearm - adduction, flexion of
thumb.
• Intrinsic postural change: flexion of
MCPJ, extension of IPJ: intrinsic - plus
deformity.
 UPPER ROOTS OF BRACHIAL PLEXUS
ERB’S PALSY
• Birth injuries - powerful blow to the
shoulder with controlateral flexion of the
cervical spine.
• C5 - C6: loss of shoulder abduction -
external rotation - elbow flexion - forearm
supination: arm in the patient’s side
internally rotated, extended at the elbow
and pronated.
• C7: Loss of elbow and wrist extension. The
palm turns upwards to the rear at the level
of the mid - thigh, the porter’s tip position.
LOWER ROOTS OF BRACHIAL PLEXUS
KLUMPKE’S PARALYSIS
• C8 - T1: Loss of all the intrinsic
muscles of the hand - flatening
and marked wasting.
• Due to the weakness or absence
of the long flexors there may be
less dramatic change in posture.
RADIAL NERVE ABOVE THE ELBOW
WRIST DROP
• Loss of wrist and finger
extensors, wrist drop posture.
• The fingers may appear to extend
remarkably well, but this is due to:
1) The tenodesis effect of wrist flexion
in extending the MCPJ and
2) Active ulnar innervated
intrinsics, extending the
interphalangeal joints.
 ULNAR NERVE AT THE WRIST
CLAW HAND
• Hyperextension of MCPJ and flexion of the IPJ of
the ring and small fingers.
• Paralysis of FDQ and lumpricals disturbs the
balance of the MP joints, which are
hyperextended by the long extensors. In the IP
joints the long extensors lose and the long
flexors gain mechanical advantage and adopt a
flexed posture.
• Ulnar clawing does not resulve when:
1) Martin - Gruber anastomosis: ulnar fibres travel
with the median nerve to the forearm.
2) MCP joint cannot hyperextend due to arthritis -
injury - stifness.
3) High ulnar nerve injuries above the FDP of the ring
- small fingers: THE ULNAR PARADOX..
ULNAR NERVE AT THE WRIST
CLAW HAND
•THE BOUVIER MANOEUVER
Important in assessing the claw hand.
Hyperextension of the MCPJ is prevented and
the patient asked to extend the finger:
• Bouvierre positive: extension of the IPJ.
• Bouvierre negative - passive positive: IPJ
extends passively (extensor apparatus
incopetent.
• Bouvierre negative - passive nagative: IPJ
fixed in flexion (skin shortening - flexor
adhesions - palmar plate contractures).
ULNAR NERVE AT THE WRIST
ULNAR ABDUCTED FINGER
• If MCPJ cannot be
hyperextended, the finger does
not claw.
• Loss of the third palmar
interosseous muscle causes the
small finger to abduct markedly
into extension.
 ULNAR NERVE AT THE WRIST
FROMMENT’S SIGN
• The patient is asked to pull a sheet of paper
with index finger and thump, while the
examiner withdraws it strongly.
• The normal patient maintains maximum
contact with the paper by extending the IPJ
• In ulnar palsy FPL is too powerful for the
combined IPJ extensors weakened by the loss
of the contribution of the Adductor Pollicis.
• Control of the MCPJ is lost, it collapses into
hyperextension and IPJ flexes
 MEDIAN NERVE BELOW THE ELBOW
BENEDICTION SIGN
• Anterior interosseous nerve palsy.
• Arises from the median nerve 4-6 cm below the
elbow. Entire motor nerve
• Supply to FPL, FDP (Radial half), PQ.
• Compression from tendinous band - accessory
muscles, vascular pathology.
• Symptoms: pain - weakness of pinch.
• During pinch the distal phalanges of the thumb
and index finger stay in extension.
• Benediction sign: Inability to flex thumb - index
finger (FDP to the middle finger many times gets
innervation from the ulnar nerve).
COMBINED ULNAR AND MEDIAN NERVE
SIMIAN HAND
• Similar to the hand of an ape.
• Full claw hand.
• Thenar and hypothenar flattening due
to muscle waisting.
• Thumb adduction and flexion.
• Also seen in Charcot -Marie - Tooth
disease.
 MALLET FINGER
• DIPJ in flexion (10° - 40°).
• Open or Close.
• Traumatic or inflammatory origin.
• Associated with avulsion fractures of
the proximal portion of the distal
phalanx.
• Division or elongation of the terminal
extensor tendon at the level of the
DIPJ.
 SWAN NECK DEFORMITY
• Hyperextension of the PIPJ and flexion of
the DIPJ.
• Excessive traction by the extensor
apparatus, inserted on the base of the
middle phalanx:
- Articular (lesion of structures which
prevent hyperextension of the PIPJ).
- Intrinsic muscle (interosseous
contracture), palmar subluxation of the
base of the proximal phalanx.
- Increase of power of EC.
• The deformity is reducible at first -
gradually becomes fixed.
 BOUTONNIERE DEFORMITY
• Flexion of the PIPJ and hyperextension of the DIPJ.
• After division, rupture or degeneration (rheumatoid
arthritis) of the central tendon of the extensor
aparratus in the dorsum of the PIPJ.
• Lateral - palmar dislocation of the lateral extensor
tendons which become flexors - the head of the
proximal phalanx is “button holed”.
• At an early stage the deformity is reducible: Haines
- Zancolli test negative, if the middle phalanx is
maintained in extension, flexion of the distal
phalanx is still possible.
• By time it becomes fixed: Haines - Zancolli test
positive, flexion of the distal phalanx not possible.
 PIANO KEY SIGN
• Indicates ulnar head subluxation
(rheumatoid patients).
• The prominent ulnar head can be
manually depressed by 5mm or
more, usually with accompanying
pain.
• When pressure is released the head
of the ulna springs back in its original
position, like a key of the piano.
 IMAGING EVALUATION
STANDARD VIEWS
• 4 views for the wrist:
(PA, L, Oblique, PA with ulnar
deviation). Central beam over
the capitate head.
• 3 views for the hand:
(PA, L, Oblique). Central beam
over the midportion of the 3rd
metacarpal.
 IMAGING EVALUATION
SPECIAL VIEWS
• Scaphoid views: Routine AP and
then full ulnar deviation, with the
central beam angled 20° towards
the elbow.
• Carpal tunnel views: the forearm
flat on the cassete and maximum
dorsiflex of the wrist. Axial view of
the hamate, pisiform and volar
margin of the trapezium.
• Stress views: Soft tissue injuries
(Gamekeeper’s Thumb)
 IMAGING EVALUATION
NORMAL ANGLES AND MEASUREMENTS

• Three carpal arcs:

Arc 1: proximal convexities of S, L, T.
Arc 2: distal concavities os S, L, T.
Arc 3: proximal convexities of C, H.

• Radial inclination: 20° (16° - 28°).

• Palmar tilt: 10° - 20°

 IMAGING EVALUATION
ARTHROGRAPHY
• Ligamentous or cartilaginous abnormalities.
• Major wrist compartments (don’t
communicate): Radiocarpal cpt, Distal
Radioulnar cpt, Midcarpal cpt.
• Under fluoroscopic control - frequent spot
filming.
• 2:1 mixture of dilute water - soluble contrast
to 1% lidocaine.
• The joints are fully distended with contrast
until the patient has mild discomfot.
• The clinical significance of some
arthrographic findings is difficult to access -
all the abnormalities on arthrography must
be carefully correlated with clinical
examination.
 IMAGING EVALUATION
RADIONUCLIDE BONE IMAGING
• Extremely sensitive but with low specificity. For evaluation of
subtle wrist and hand injuries.
• Technetium - 99m coupled to phosphate compounds.
• Phase I: angiography, first 1 - 2 m provides blood flow information.
• Phase II: blood pool images, 5 m after the injection, provides soft
tissues information..
• Phase III: 2 - 3 h . Detects cartilage and bone information.
• Acute phase after trauma (2 - 4 w): All three phases are positive.
• Subacute stage (4 - 12 w):Phase I becomes normal.
• Chronic stage (>12 w): Only stage III positive.
• Diagnosis of RSD - AVN
 IMAGING EVALUATION
COMPUTED TOMOGRAPHY (CT)

• Improved contrast resolution and

planar representation of the carpal
bones without the superimposition
of anatomic structures.
• Primary images in different planes.
• Occult fractures of wrist bones -
carpal fracture non - unions, bone
graft incorporation, osseous
fusion.
 IMAGING EVALUATION
MAGNETIC RESONANCE IMAGING (MRI)

• Simultaneous and direct vision of

bone cartilage and soft tissue.
• Carpal ligamentous
disruptions, DRUJ instability, TFCC
disruptions, occult
fractures, tendon
ruptures, RSD, AVN.
• T1 - weighted SE sequences and 3D
-GRE sequenses performed.
 IMAGING EVALUATION
ULTRASONOGRAPHY
• Examining structures in “real
time”, during active motion.
• Provides details of soft tissues.
• Function and anatomic
characteristics of
tendons, ligaments, cartilage, soft
tissue masses.
• Highly machine and operator
dependent technique.
 WRIST ARTHROSCOPY
• Indications: Evaluation of ligamentous
injuries, examination of joint articular
surfaces, removal of loose
bodies, synovium biopsy, irrigation and
joint debridement, confirmation and
supplementary to wrist arthrography.
• The usual arthroscopic portals are
located between the extensor
compartments of the wrist.
• Arthroscopy is general more accurate in
identifying the location and size of TFCC
and interosseous ligament injuries.
 ELECTRODIAGNOSIS
ELECTROMYOGRAPHY - NERVE CONDUCTION

• Electromyography: Stimulus applied directly to the

muscle - the different response to different strengths
of stimulus is indication of the condition of the
muscle.
• Nerve conduction: Apply stimulating electrodes over
the course of the motor nerve proximally na
drecording the muscle activity. The time between the
stimulus and the action potential is the distal latency.
• After 3w denervation can be confirmed on EMG.
• Division or compression neuropathies can be
detected and localized.
• Re - innervation can be detected prior to clinical
evidence of motor return.
 REFERENCES
• Campbell’s Operative Orthopaedics.
• Examination of the hand and wrist. R. Tubiana, J
Thomine, E. Mackin.
• Journal of Hand Surgery.
• Manual of acute hand injuries. D.S. Martin, E.D.
Collins.

• The hand: Diagnosis and indications. G. Lister.

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