Orthopaedic Assessments

Lectures 23 & 24

The Wrist &

Hand
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
 Wrist & Hand – Applied Anatomy

Distal Radioulnar Joint

• Resting Pos'n 10° of supination

• Close Pack Pos'n 5° of supination
• Capsular Pattern pain at extreme of
rotation
 Wrist & Hand – Applied Anatomy

Radiocarpal (Wrist) Joint

• Resting Pos'n neutral with slight

ulnar deviation
• Close Pack Pos'n extension
• Capsular Pattern flexion and
extension equally
limited
 Wrist & Hand – Applied Anatomy

Radiocarpal (Wrist) Joint

• Radius articulates with the scaphoid

and lunate
• Lunate and triquetrium articulate with
the TFCC
 Wrist & Hand – Applied Anatomy

Intercarpal Joints

• Resting Pos'n neutral or slight

flexion
• Close Pack Pos'n extension
• Capsular Pattern none
 Wrist & Hand – Applied Anatomy

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)
Wrist & Hand – Applied Anatomy
 Wrist & Hand – Applied Anatomy

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
 Wrist & Hand – Applied Anatomy

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
 Wrist & Hand – Applied Anatomy

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
 Wrist & Hand – Applied Anatomy

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
 Wrist & Hand – Applied Anatomy

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
 Wrist & Hand – Applied Anatomy

Metacarpophalangeal Joints

• Resting Pos'n slight flexion

• Close Pack Pos'n THUMB: full
opposition
FINGERS: full
flexion
• Capsular Pattern flexion, then
extension
 Wrist & Hand – Applied Anatomy

Metacarpophalangeal Joints
nd rd
• 2 & 3 metacarpophalangeal joints
are generally immobile and are the
primary stabilizing factor of the hand
 Wrist & Hand – Applied Anatomy

Interphalangeal Joints

• Resting Pos'n slight flexion

• Close Pack Pos'n full flexion
• Capsular Pattern flexion, then
extension
 Wrist & Hand – Applied Anatomy

• 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
Wrist & Hand – Patient Observation
 Wrist & Hand – Patient Observation

• 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
 Wrist & Hand – Patient Observation

• 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
Wrist & Hand – Patient Observation
 Wrist & Hand – Patient Observation

• Duputryen's
Contracture
• the connective
tissue under the
skin of your palm
contracts and
toughens
(thickens) over
time
Wrist & Hand – Patient Observation
 Wrist & Hand – Patient Observation

• 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
Wrist & Hand – Patient Observation
 Wrist & Hand – Patient Observation
• Thenar / Hypothenar Atrophy
– Thenar: median n.
– Hypothenar: ulnar n.
– First dorsal interosseous muscle: C7 nerve root
Wrist & Hand – Patient Observation
 Wrist & Hand – Patient Observation

• 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
Wrist & Hand – Patient Observation
Wrist & Hand – Patient Observation
 Wrist & Hand – Patient Observation

• 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
Wrist & Hand – Patient Observation
Wrist & Hand – Patient Observation
Wrist & Hand – Patient Observation
Wrist & Hand – Patient Observation
 Wrist & Hand – Patient Observation

• Boutonniere Deformity
–Extension of the
metacarpophalangeal and DIP
joints, flexion of the PIP joint
–Rupture of the extensor tendon
over joint
•Trauma, RA
Wrist & Hand – Patient Observation
 Wrist & Hand – Patient Observation

• 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
 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
Wrist & Hand – Patient Observation
 Wrist & Hand – Patient Observation

• 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
 Wrist & Hand – Patient Observation

• 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
 Wrist & Hand – Patient Observation

• Drop-Wrist Deformity
–Radial nerve palsy leading to inability
of extensor muscles to function
• Wrist and fingers cannot be
extended
Wrist & Hand – Patient Observation
 Wrist & Hand – Patient Observation

• 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
Wrist & Hand – Patient Observation
 Wrist & Hand – Patient Observation

• 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
Wrist & Hand – Patient Observation
Wrist & Hand – Patient Observation
EXAMINATION
 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 of
WRIST AND
HAND
 Wrist & Hand – Examination

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°
 Wrist & Hand – Examination

ACTIVE ROM (cont'd)

• Finger flexion
–MCP 85° - 90°
–PIP 100°
–DIP 80° - 90°
• Finger extension
–MCP 30° - 45°
–PIP 0°
–DIP 20°
 Wrist & Hand – Examination

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°
 Wrist & Hand – Examination

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)
 Wrist & Hand – Examination

THUMB
ABDUCTION &
ADDUCTION

THUMB FLEXION
& EXTENSION
 Wrist & Hand – Examination

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
 Wrist & Hand – Examination

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
 Wrist & Hand – Examination

ISOMETRIC RESISTED ROM

• Pronation
• Supination
• Radial deviation
• Ulnar deviation
• Wrist flexion
• Wrist extension
• Finger flexion
• Finger extension
 Wrist & Hand – Examination

ISOMETRIC RESISTED ROM (cont'd)

• Finger abduction
• Finger adduction
• Thumb flexion
• Thumb extension
• Thumb abduction
• Thumb adduction
• Opposition
 Wrist & Hand – Examination

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
 Wrist & Hand – Examination

FUCTIONAL
rd
• Middle (3 ) finger – strongest
–Important for power and precision
th
• Little (5 ) finger – enhances power grip,
affects the capacity of the hand, holds
objects against the hypothenar eminence
• Ring (4th) finger – least functional of the
fingers
 Wrist & Hand – Examination

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
 Wrist & Hand – Examination

FUCTIONAL

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

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 – Circulatory
• Allen's Test
– Finkelstein's Test
– Instability Tests
– Bunnel-Littler Test (ligamentous)
• Neurological • Shuck Test
– Tinel's Sign at the • Thumb Ulnar
wrist Collateral Ligament
instability Test
– Phalen's Test
– Other
– Reverse Phalen's • Murphy's Sign
Test (Skyline Sign)
– Froment's
 Wrist & Hand – Special Tests

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
Wrist & Hand – Special Tests
 Wrist & Hand – Special Tests

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 PIP
INDICATES: tight intrinsic muscles or
contracture of the joint capsule (ie.
arthritide)
Wrist & Hand – Special Tests
 Wrist & Hand – Special Tests

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
Wrist & Hand – Special Tests
Wrist & Hand – Special Tests
 Wrist & Hand – Special Tests

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
INDICATES: carpal tunnel syndrome
Wrist & Hand – Special Tests
 Wrist & Hand – Special Tests

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
INDICATES: carpal tunnel syndrome
Wrist & Hand – Special Tests
 Wrist & Hand – Special Tests

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 Tests
 Wrist & Hand – Special Tests
ALLEN'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
 Wrist & Hand – Special Tests

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
 Wrist & Hand – Special Tests

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
 Wrist & Hand – Special Tests

MURPHY'S SIGN (SKYLINE SIGN)

(1) Client: make a fist and hold arm
straight out

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