Overview An overview of some of the common physical exam maneuvers used to examine the hand and wrist Common physical exam maneuvers used to examine the hand and wrist Watson test Scapholunate (SL) instability - dynamic Lunotriquetral ballotment test (Reagan test) Lunotriquetral (LT) instability - dynamic Kleinman shear test LT instability - dynamic Lichtman test Midcarpal instability - dynamic TFCC grind TFCC pathology ECU snap test ECU instability Piano key sign DRUJ instability Fovea sign TFCC pathology or ulnotriquetral ligament split tear Inspection Skin discoloration erythema (cellulitis) white (arterial insufficiency) blue/purple (venous congestion) black spots (melanoma) trophic changes (i.e. increased hair growth or altered sweat production) can represent derangement of sympathetic nervous system scars/wounds Swelling Muscle atrophy thenar atrophy median nerve involvement caused by carpal tunnel syndrome interossei atrophy ulnar nerve involvement caused by cubital tunnel or cervical radiculopathy subcutaneous atrophy locally post-steroid injection Deformity asymmetry angulation rotation absence of normal anatomy (previous amputation) cascade sign fingers converge toward the scaphoid tubercle when flexed at the MCPJ and PIPJ if one or more fingers do not converge, then trauma to the digits has likely altered normal alignment Palpation Masses (ganglions, nodules) Temperature warm: infection, inflammation cool: vascular pathology Tenderness Crepitus (fracture) Clicking or snapping (tendonitis) Joint effusion (infection, inflammation, trauma) Range of Motion Active and passive Finger MCP: 0° extension to 85° of flexion PIP: 0° extension to 110° of flexion DIP: 0° extension to 65° of flexion Wrist 60° flexion 60° extension 50° radioulnar deviation arc Neurovascular Exam Sensation two-point discrimination Motor radial nerve: test thumb IP joint extension against resistence median nerve recurrent motor branch: palmar abduction of thumb anterior interosseous branch: flexion of thumb IP and index DIP ("A-OK sign") ulnar nerve: cross-fingers or abduct fingers against resistence Vascular radial pulse ulnar pulse Allen's test capillary refill Special Tests Palpation grind test used to test for pathology at the thumb carpometacarpal joint (CMC) examiners applies axial load to first metacarpal and rotates or "grinds" it positive findings: pain, crepitus, instability Finkelstein's used to test for DeQuervain's tenosynovitis patient makes fist with fingers overlying thumb examiner gently ulnarly deviates the wrist positive findings: pain along the 1st compartment Range of motion flexor profundus used to test continuity of FDP tendons MCP + PIP joints held in extension while patient asked to flex FDP, thereby isolating FDP (from FDS) as the only tendon capable of flexing the finger flexor sublimus used to test for continuity of FDS tendon MCP, PIP and DIP of all fingers held in extension with hand flat and palm up; the finger to be tested is then allowed to flex at PIP joint. Bunnel's test examiner passively flexes PIPJ twice first with MCP in extension next with MCP held in flexion intrinsic tightness present if PIP can be flexed easily when MCP is flexed but NOT when MCP is extended extrinsic tightness present if PIP can be flexed easily when MCP is extended but NOT when MCP is flexed Stability assessment scaphoid shift test (Watson's test) tests for scapholunate ligament tear examiner places thumb on distal pole of scaphoid on palmar side of wrist and applies constant pressure as the wrist is radially and ulnarly deviated dorsal wrist pain or "clunk" may indicate instability lunotriquetral ballottement tests for lunotriquetral ligament tear examiner secures the pisotriquetral unit with the thumb and index finger of one hand and the lunate with the other hand anterior and posterior stresses are placed on the LT joint positive findings are increased laxity and accompanying pain midcarpal instability examiner stabilizes distal radius and ulna with non-dominant hand and moves patients wrist from radial deviation to ulnar deviation, whilst applying an axial load a positive test occurs when a clunk is felt when the wrist is ulnarly deviated ulnar carpal abutement tests for TFCC tear or ulnar-carpal impingement examiner ulnarly deviates wrist with axial compression positive if test reproduces pain or a 'pop' or 'click' is heard Gamekeeper's tests for ulnar collateral ligament tear at MCP of thumb examiner stresses first MCPJ into radial deviation with MCPJ in fully flexed and extended positions positive test if > 30 degrees of laxity in both positions (or gross laxity compared to other side) Nerve assessment Tinel's tests for carpal tunnel syndrome examiner percusses with two fingers over distal palmar crease in the midline positive if patient reports paresthesias in median nerve distribution Phalen's tests for carpal tunnel syndrome with the hands pointed up, the patient's wrist is allowed to flex by gravity in palmar flexion for 2 minutes maximum positive if patient reports paresthesias in median nerve distribution Froment's sign tests for ulnar nerve motor weakness patient asked to hold a piece of paper between thumb and radial side of index positive if as the paper is pulled away by the examiner the patient flexes the thumb IP joint in an attempt to hold on to paper Wartenberg's sign tests ulnar nerve motor weakness patient asked to hold fingers fully adducted with MCP, PIP, and DIP joints fully extended positive if small finger drifts away from others into abduction Jeanne's sign tests for ulnar nerve motor weakness ask patient to demosntrate key pinch positive finding if patients first MCP joint is hyperextended