Professional Documents
Culture Documents
of the
Hand and Wrist
A.Mazaherinezhad
MD. Sportsmedicine Department,
Assistant professor, IUMS
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OBJECTIVES
Review the clinical anatomy and
physical exam of the wrist and hand
Formulate a pathoanatomic diagnosis
in the clinical setting
Discuss common clinical conditions
that can be elicited from the physical
exam
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INTRODUCTION
The least protected joints
Extremely vulnerable to injury
Difficult and complex examination
Diagnosis often vague
If no fracture = wrist strain or sprain
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Bony
Anatomy
Phalanges: 14
Sesamoids: 2
Metacarpals: 5
Carpals
Proximal row: 4
Distal row: 4
Listers
tubercle
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HISTORY
Age
Handedness
Chief complaint
Occupation
Previous injury
Previous surgery
Sx related to
specific activities
What exacerbates
What improves
Frequency
Duration
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HISTORY
4 principle
mechanisms of injury
Throwing
Weight bearing
Twisting
Impact
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INITIAL STEPS
INSPECTION
SWELLING
REDNESS
ATROPHY
PALPATION
TENDERNESS
WARMTH
RANGE OF MOTION
FLEXION
EXTENSION
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PHYSICAL EXAM
Inspection
Palpation
Range of Motion
Neurologic Exam
Special Tests
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INSPECTION
Observe upper
extremity as patient
enters room
Examine hand in
function
Deformities
Attitude of the hand
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INSPECTION
Palmar Surface
Creases
Thenar and
Hypothenar
Eminence
Arched Framework
Hills and Valleys
Web Spaces
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Cascade sign
Assure all fingers
point to scaphoid
area when flexed at
PIPs
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INSPECTION of Dorsal
Hand and Wrist
Hills and Valleys
Height of metacarpal heads
Finger nails
Pale or white=anemia or circulatory
Spoon shaped=fungal infection
Clubbed=respiratory or congenital heart
Deformities
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Ganglion
Cystic structure
that arises from
synovial sheath
Discrete mass
Dull ache
Dorsal or Volar
aspect
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Boutonniere Deformity
Tear or stretch of
the central extensor
tendon at PIP
Note: unopposed
flexion at PIP
Extension at DIP
Trauma or
inflammatory
arthritis
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Osteoarthritis
Heberdens nodes:
DIP
Bouchards nodes:
PIP
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Rheumatoid Arthritis
MCP swelling
Swan neck
deformities
Ulnar deviation
at MCP joints
Nodules along
tendon sheaths
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Mallet Finger
Hyperflexion injury
Ruptured terminal
extensor mechanism
at DIP
Incomplete
extension of DIP
joint or extensor lag
Treatment:
stack splint
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Dupuytrens Contractures
Palmar or digital
fibromatosis
Flexion contracture
Painless nodules near
palmar crease
Male> Female
Epilepsy, diabetes,
pulmonary dz,
alcoholism
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RANGE OF MOTION
Active range of motion
Passive range of motion if unable to
actively move joint
Bliateral comparison
To determine degrees of restriction
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RANGE OF MOTION
Wrist
Flexion
Extension
Radial deviation
Ulnar deviation
Ulnar deviation is
greater than radial
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Mobility :
(pronosupination)
To test pronosupination, the patient is asked to keep his or
her elbows close to the body and to turn the palm up and
down alternatively. One arm of the goniometer is placed
parallel to the axis of the humerus, and the other along the
distal part of the forearm (Figure 1 & 2).
One should avoid measuring pronosupination with a stick in
the patient's hands, as the pronosupination mobility is
increased by the passive rotatory mobility of the carpus,
which may be as high as 40.
If the neutral prono-supination position is defined as zero
(with the elbow flexed and maintained against the chest, the
thumb must be raised up):
Normal pronation varies between 60 and 90,
Normal supination, between 45 and 80.
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Figure 1:
Measurement of
pronation:
The vertical arm of
the goniometer is
placed in the axis of
the arm and the
horizontal arm on the
dorsal surface of the
wrist, but not the
hand.
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Figure 2:
Measurement of
supination.
The horizontal
arm is placed on
the volar surface
of the wrist.
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Flexion-extension
Flexion-extension mobility is measured by placing the
goniometer on the palm for wrist extension, and along
the dorsum of the hand for wrist flexion, over the axis
of the third metacarpal bone (figure 3 & 4).
Normal values vary among individuals and may reach 85
of flexion or extension.
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Figure 4:
Masurement of extension:
The goniometer is placed
anteriorly on the wrist.
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Measurement of strength
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RANGE OF MOTION
Fingers
Flexion/extension at MCP, PIP, DIP
Tight fist and open
Do all fingers work in unison
ABDuction/ADDuction at MCP
Spread fingers apart and then back
together
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CLINICAL EXAMINATION OF
THE WRIST
The normal wrist :
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PALPATION of Skin
Warmth?
Dryness?
Anhydrosis= nerve damage
Scars
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PALPATION of Wrist
Dorsum
Radial Styloid
Scaphoid
1st MC/Trapezium
jt
Lunate
Listers Tubercle
Ulnar Styloid
TFCC
Triquetrum
Pisiform
Hook of Hamate
Guyons Tunnel
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Conditions of examination :
The wrist must be examined with the forearm free of clothing and jewelry.
For a satisfactory examination, the patient and the examiner should be
comfortably seated.
The ideal solution is to place the patient's forearm on a narrow examination
table whose height may vary.
In clinical practice, the easiest solution is to sit very close to the patient so
that his or her hand rests on the examiner's knee, with the patient's elbow
resting on his thigh.
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Ulnar
styloid
Figure 6:
Figure 7:
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To examine a
wrist
correctly, one
should
mentally
project the
bones onto
the skin.
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Radial
styloid
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Figure 8:
Figure 9:
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Figure 8:
Figure 9:
Figure 10:
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Figure 13:
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PALPATION
Palmar Aspect
Pisiform and Hamate
Tunnel of Guyon
Ulnar Artery
Carpal Tunnel
Flexor Carpi Radialis
Flexor Carpi Ulnaris
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pisiform
when the wrist is in extension (Figure
15). Ulnarly, the pisiform is easily
palpated, just distal to the distal
wrist crease.
Figure15:
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Tunnn
el of
Guyon
Pisiform and
Hamate
palpation
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metacarpal bone.
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Tunnel of Guyon
Depression between
pisiform and hook of
hamate
Contains ulnar nerve
and artery
Site of compression
injuries
unusually tender if
pathology is present
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Flexor carpi
ulnaris
Palmaris longus
Flexor carpi
radialis
Volar flexor
tendons
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Scapholunate Dissociation
Diagnosis often missed
Pain, swelling, and decreased ROM
Pressure over scaphoid tuberosity elicits
pain
Greatest pain over dorsal scapholunate
area, accentuated with dorsiflexion
X-ray shows widening of scapholunate joint
space by at least 3 mm
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Triangular Fibro-Cartilage
Complex palpation (TFCC)
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PALPATION of HAND
Bone
Metacarpals - 5
Phalanges - 14
Palpate for swelling, tenderness
Assess for symmetry
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PALPATION
Soft tissue
6 Dorsal
Compartments
Transport extensor
tendons
2 Palmar Tunnels
Transport nerves,
arteries, flexor
tendons
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DeQuervains Tenosynovitis
Inflammation of
EXT Pollicis Brevis
and ABD Pollicis
Longus tendons
Tenderness 1st Dorsal
Compartment
Finkelsteins Test
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DeQuervains Tenosynovitis
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Intersection Syndrome
(Squeaker Wrist)
Similar to DeQuervains
tenosynovitis
Peritendinitis related to
bursal inflammation at the
junction of the 1st and 2nd
dorsal compartments
Overuse of the radial
extensor of the wrist
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Intersection Syndrome
(Squeaker Wrist)
Seen in gymnasts, rowers,
weightlifters, racket sports
Proximal to DeQuervains- 4-6 cm
from radiocarpal joint
Crepitation or squeaking can be heard
with passive or active ROM
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Carpal Tunnel
Deep to palmaris
longus
Contains median
nerve and finger
flexor tendons
Most common
overuse injury of
the wrist
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Symptoms
Aching in hand and arm
Nocturnal or AM paresthesias
Shaking to obtain relief
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Phalens Test:
both wrists
maximally flexed for
1 minute
Tinels Test
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PALPATION
Palm of Hand
Thenar Eminence
3 muscles of thumb
Atrophy seen in carpal tunnel syndrome
Hypothenar Eminance
3 muscles of little finger
Atrophy with ulnar nerve compression
Palmar Aponeurosis
Dupuytrens Contracture
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PALPATION of Fingers
Finger Flexor Tendons
Extensor Tendons
Tufts of Fingers
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SPECIAL TESTS
Long Finger Flexor Test
Flexor Digitorum Superficialis Test
Flex finger at PIP
The only functioning tendon at the PIP
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Trigger Finger
Stenosing flexor
tenosynovitis
Painful snap or lock
Palpate nodule as
digit flexed and
extended
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Flexor Tenosynovitis
Tendon sheath infection
Usually due to a puncture wound
Bacterial skin flora
Relative surgical emergency
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Flexor Tenosynovitis
RANGE OF MOTION
Thumb
Thumb flexion/extension at MCP and
IP
Touch pad at base of little finger
Skiers Thumb
Gamekeepers Thumb
Ulnar Collateral
Ligament rupture of
the thumb MCP joint
Instability, weak and
ineffective pinch
Radially directed
stress at MCP jointstable if opens <35
degrees
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NEUROLOGIC EXAM
Muscular assessment using grading
system
Sensation testing
Bilateral comparison
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NEUROLOGIC EXAM
Muscle Testing
WRIST
EXT C6
FLEX C7
FINGERS
EXT C7
FLEX C8
ABD T1
ADD T1
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Sensation Testing
Dorsal hand
Radial hand
SHOULDER
ABDUCTION
BICEPS
LATERAL ARM
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WRIST
EXTENSION
BRACHIORADIALIS
LATERAL FOREARM
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WRIST FLEXION
FINGER EXTENSION
TRICEPS
MIDDLE FINGER
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MEDIAL FOREARM
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FINGER ABUCTION
MEDIAL ARM
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RADIOLOGIC STUDIES
AP and Lateral of
hand and wrist
Consider Obliques
and special views if
fracture suspected
but not seen on AP
and Lateral
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EXAMINATION OF RELATED
AREAS
Referred pain can be
due to:
Herniated cervical
discs
Osteoarthritis
Brachial plexus outlet
syndrome
Elbow and shoulder
entrapment syndrome
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Scapholunate instability:
The mechanism of scapholunate injury includes a fall onto a hyperextended wrist
with the forearm in pronation and the impact point on the thenar eminence .
Radial pain and progressive loss of strength are usual . Loss of mobility appears
much later. Patients may sometimes complain of a snapping wrist which usually
occurs during the passage from radial deviation to neutral with the wrist in
flexion.
In ulnar deviation, the snap represents the action of the scaphoid on the lunate
bone and the sudden correction of the proximal carpal row into dorsiflexion.
With wrist flexion, a snap may represent penetration of the capitate into the
scapholunate interval (rare), or the dorsal subluxation of the scaphoid on the
posterior margin of the radius .
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Figure 21:
The wrist-flexion finger-extension
maneuver. This maneuver induces loads
into the carpus that arouses pain at the
scapholunate space.
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Lunotriquetral instability:
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Figure 23:
The lunotriquetral
ballottement test
(Reagan's test)
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Figure 24:
The Kleinman's
test.
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(26b)
(26c)
In Fig 26a, the examiner places the wrist in radial deviation while
palpating the triquetrum. He then moves the wrist in neutral
(26b) and ulnar (26c) deviation to appreciate the depression of
the triquetrum with ulnar deviation and prominence of the
triquetrum with radial deviation that should be compared to the
contralateral
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In case of dorsal ulna subluxation, the protrusion of the ulnar head may
be clearly visible when viewed laterally, and unlike what occurs in the
normal wrist, does not disappear if the injured wrist is flexed.
Anterior ulnar dislocation
makes the dorsal skin depress and
limits pronation.
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Figure 29:
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Figure 30:
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QUESTIONS
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