wrist/hand eval

history

• how did this injury occur? (mechanism)

• when did you hurt your hand/wrist?

• Where does it hurt?

• Did u hear any sounds or feel a pop?

• have you injured this hand/wrist before?

observation

• attitude of the hand

• bilateral comparison of wrist/hand (swelling, deformity, discoloration)

• palmar surface(DIP, PIP, dist. and prox. palmar, and thenar creases; hypothenar eminence and thenar eminence)

• dorsal surface (knuckles, fingernails)

attitude of the hand

the way the hand naturally rests and bilaterally compare, naturally slightly flexed MCP and IP joints, almost parallel fingers

proximal palmar crease

distal palmar crease

thenar crease

thenar eminence

hypothenar eminence

DIP creases

PIP creases

IP crease

Palpation(palpate the following noting point tenderness, deformity, etc.)

Soft tissue

• tunnels 1-6

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Bony

• Radius styloid process

• ulna styloid process

• scaphoid

• trapezium

• metacarpals

• phalanges

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• Carpal tunnel

• Tunnel of guyon

• thenar eminence

• hypothenar eminence

• palmar aponeurosis

flexor digitorum superficialis test

goes only to middle phalanges

active

• hold other fingers in extension, especially DIP, deactivate profundus

• bend the finger

• negative if still can flex, but distal can’t bend which is normal

• positive if can’t flex

looking for flexion of PIP

flexor digitorum profundus test

goes to distal joint

active

• hold PIP joint of the specific finger

• negative if DIP can flex

• positive if can’t curl the finger, might feel a tug though

bunnel-littler test (intrinsic m. vs. capsule)

passive

note: capsule around joints doesn’t change, so it’s muscle tightness if stiff in one position, but if both positions are stiff, it’s the capsule that’s tight. changing proximal joint changes the muscle length.

PIP joint

• hyperextend MCP

• feel for pip mobility

• release and test again(w/o MCP hyperextended)

• feel for stiffness

-

• same amount of stiffness(resistance) in both-the tighest structure is the capsule

• difference of stiffness in the 2 phases-the intrinsic muscle is the tightest structure

retinacular test

passive

test for DIP joint

• hold proximal joint and feel for mobility

• then release the proximal joint and feel for difference in stiffness

-

• same amount of stiffness(resistance) in both-the tighest structure is the capsule

• difference of stiffness in the 2 phases-the retinaculum is the tightest structure

allen test(circulation)

for the wrist

pumping motion like 5 times, then squeeze tight around the wrist, release one artery but letting go of a finger, then redo with releasing the other one(reference from anatomical position, duh: medial side is the ulnar artery, lateral is the radial)

Even if one is blocked the other should help w/circulation, helps figure out which artery isn’t supplying blood

positive sign-not seeing refill

finklestein test

test for dequervain’s

• dequervain’s disease-tenosynovitis around anatomical snuffbox area

• test for inflammation of the sleeve around tendons

tenosynovitis-inflammation of sleeve around tendons

• tuck thumb in(flex) and flex fingers and slowly ulnar deviate

• should feel similar on both hands(pain)

• positive-not the same feeling on both hands

tinel sign

tap over median nerve(passes through carpal tunnel) neurological symptoms to the fingers (median nerve supplies)

phalen’s test

tell them to put backs of hands together and press together for 30 seconds, compressing it, after 30 seconds, positive sign is neuro symptoms of median nerve

tenosynovitis

inflammation of sleeve around tendons

dequervain’s disease

tenosynovitis around anatomical snuffbox area

tests for carpal tunnel syndrome(name 2)

• tinel sign test

• phalen’s test

palpate the radius styloid process

lateral when the hand is in anatomical position, can palpate the distal tip and there’s a small but distinct groove on lateral edge

palpate the ulna styloid process

bumpy process on the medial side, visible too, easier palpation by radially deviating and having the extensor carpi ulnaris tendon contract

palpate the scaphoid(carpal navicular)

in anatomical snuffbox, distal to the radial styloid process, ulnar deviate to make it palpable

palpate the trapezium

distal to the snuffbox to palpate near its articulation with the 1st metacarpal; (to feel the trapezium and MT articulation, flex and extend thumb)

palpate metacarpals

palpate with thumb, index, and middle fingers, the dorsal and radial sides are easy to palpate

palpate the phalanges

palpate for differences(14 per hand), feel and check for swelling, tenderness, symmetry…

palpate the tunnel of guyon

at the hook of hamate on palmar side of hand, crossing of a line between the 4-5 digits and 1-2 digits

palpate the carpal tunnel

deep to palmaris longus(palmaris longus can be seen by opposing thumb to pinkie, some people don’t have it), proximal side is pisiform, navicular and the distal side is hamate hook and trapezium, home for median nerve and finger flexors to pass through

palpate the thenar eminence

base of thumb, dominant hand may have a more pronounced eminence, median nerve supplies to muscles of the thenar eminence

palpate the hypothenar eminence

proximal to pinkie to pisiform, ulnar nerve supplies the muscles by/in the hypothenar eminence

palpate the palmar aponeurosis

the palmar fascia extends to base of fingers, probe to check for thickened areas on the palmar side of the hand

tunnels 1-6 and the tendons

tunnel 1-abductor pollicis longus, extensor pollicis brevis

tunnel 2-extensor carpi radialis longus, extensor carpi radialis brevis

tunnel 3-extensor pollicis longus

tunnel 4-extensor digitorum, extensor communis, extensor indicis

tunnel 5-extensor digiti minimi

tunnel 6-extensor carpi ulnaris