Clinical Examination of the Hand and Wrist

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

INTRODUCTION: Hand and Wrist Series of complex, delicately balanced joints Function is integral to every act of daily living Most active portion of the upper extremity

INTRODUCTION The least protected joints Extremely vulnerable to injury Difficult and complex examination Diagnosis often vague –If no fracture = “wrist strain or sprain” Bilateral comparison useful

Bony Anatomy Phalanges: 14 Sesamoids: 2 Metacarpals: 5 Carpals –Proximal row: 4 –Distal row: 4 Radius and Ulna Lister’s tubercle

ANATOMY Muscles /Tendons –Volar wrist- 6 –Dorsal wrist- 9 6 compartments –Volar hand- 10 –Dorsal hand- dorsal interossei Nerves - 3 –Median –Ulnar –Radial Arteries - 2

HISTORY Age Handedness Chief complaint Occupation Previous injury Previous surgery Sx related to specific activities What exacerbates What improves Frequency Duration

HISTORY 4 principle mechanisms of injury –Throwing –Weight bearing –Twisting –Impact

The Wrist Complex The wrist (carpus) consists of two compound joints: 1. radiocarpal jts 2. midcarpal jts (wrist complex)

The radiocarpal jts is composed of the radius and the radioulnar disk, with the scaphoid (S), lunate (L), and the triquetrum (Tq). The midcarpal joint is composed of the scaphoid, lunate, and triquetrum with the trapezium (Tp), the trapezoid (Tz), the capitate (C), and the hamate (H) The Wrist Complex

The major contribution of the wrist complex –1.to control length-tension relationships in the multi articular hand muscles – 2. allow fine adjustment of grip –3. The wrist muscles appear to be designed for balance and control The adjustments in the length-tension relationship of the extrinsic hand muscles that occur at the wrist cannot be replaced by compensatory movements of the shoulder, elbow, or forearm (radio ulnar joint).

Range of motion The wrist complex is biaxial motions of extension/flexion around coronal axis ulnar deviation/radial deviation around an anteroposterior axis. Pronation / supination may found especially at the radiocarpal joint Normal ranges are 65 to 85 of flexion, 60 to 85 of extension, 15 to 21 of radial deviation, 20 to 45 of ulnar deviation.

Proximal and Distal Segments of the Radiocarpal Joint proximal joint surface is composed of – (1) lateral radial facet articulates with scaphoid; –(2) medial radial facet articulates with lunate –(3) triangular fibrocartilage complex TFCC which articulates with triquetrum, although it also has some contact with the lunate in the neutral wrist

Proximal and Distal Segments of the Radiocarpal Joint proximal radiocarpal joint surface is oblique, angled slightly volarly and ulnarly. A normal angle of 23 of inclination of the radius in the frontal plane, with the distal radius about 12 mm long on the radial side than on the ulnar side.

tilted 11 volarly posterior radius slightly longer B. A normal angulation of inclination of about 11 of the radius volarly in the sagittal plane Proximal and Distal Segments of the Radiocarpal Joint

proximal joint surface result in a greater range of flexion than extension greater ulnar deviation than radial deviation for radiocarpal joint. total range of flexion/extension is greater than total range of radial/ulnar deviation.

Proximal and Distal Segments of the Radiocarpal Joint The pisiform functions entirely as a sesamoid bone, to increase the moment arm (MA) of the flexor carpi ulnaris (FCU) tendon that envelops it.

B. Dorsal wrist ligaments form a horizontal V, adding to radiocarpal stability Dorsal wrist ligaments form a horizontal V, adding to radiocarpal stability.

Flexion/Extension of the Wrist motion begins with e wrist in full flexion. Active extension is initiated at distal carpal row and at firmly attached metacarpals by wrist extensor muscles attached to those bones. distal carpals (capitate, hamate, trapezium, and trapezoid) glide on the relatively fixed proximal bones (scaphoid, lunate, and triquetrum).

Although the surface configurations of the midcarpal joint are complex distal carpal row effectively glides in the same direction as motion of the hand. When the wrist complex reaches neutral (long axis of the third metacarpal in line with the long axis of the forearm), ligaments spanning the capitate and scaphoid draw the capitate and scaphoid together into a close packed position. Flexion/Extension of the Wrist

2. Continued extensor force now moves the combined unit of the distal carpal row and the scaphoid on the relatively fixed lunate and triquetrum. At approximately 45 of extension the scapholunate interosseous ligament brings the scaphoid and lunate into close-packed position. This unites all the carpals and causes them to function as a single unit.

Flexion/Extension of the Wrist 3. Completion of wrist complex extension occurs as proximal articular surface of carpals move as a relatively solid unit on the radius. All ligaments become taut as full extension is reached and entire wrist complex is close packed.

Radial/Ulnar Deviation of Wrist In radial deviation, carpals slide ulnarly on radius produces deviation of proximal and distal carpals radially, but simultaneous flexion of proximal carpals and extension of distal carpals (with observations of accompanying pronation/supination With radial deviation of the wrist (A), the flexion of the scaphoid makes the scaphoid appear shorter than when the scapoid extends during ulnar deviation (B). C, capitate; L, lunate; S, scaphoid.

Functional Range of Motion hand activities required a functional wrist motion of – 10 of flexion and 35 of extension hand function completed in –60 extension,54 flexion, –40 ulnar deviation, 17 radial deviation. surgeon commonly chooses an optimal functional position of approximately 20 of extension and 10 of ulnar deviation This extended position, positions the long digital flexors for maximal force generation in prehension activities

PHYSICAL EXAM Inspection Palpation Range of Motion Neurologic Exam Special Tests

Surface Features of Forearm and Wrist Ulna Radius Brachioradialis muscle Flexor carpi radialis muscle Palmaris longus muscle Flexor digitorum superficialis muscle Flexor carpi ulnaris muscle Radial artery Pisiform bone Wrist creases Copyright 2011, John Wiley & Sons, Inc.

Surface Features of the Forearm and Wrist Copyright 2011, John Wiley & Sons, Inc.

Surface Features of the Forearm and Wrist

Copyright 2011, John Wiley & Sons, Inc. Surface Features of the Forearm and Wrist

Surface Features of the Hand Knuckles Dorsal venous network of the hand (dorsal venous arch). Tendon of extensor digiti minimi muscle Tendons of extensor digitorum muscle Copyright 2011, John Wiley & Sons, Inc.

INSPECTION Observe upper extremity as patient enters room Examine hand in function Deformities Attitude of the hand

INSPECTION Palmar Surface Creases Thenar and Hypothenar Eminence Arched Framework Hills and Valleys Web Spaces

Cascade sign Assure all fingers point to scaphoid area when flexed at PIPs

Volar Wrist Musculature Six muscles have tendons crossing the volar aspect of the wrist and, therefore, are capable of creating a wrist flexion movement

These are Palmaris longus (PL), flexor carpi radialis (FCR), Flexor carpi ulnaris (FCU), the flexor digitorum superficialis (FDS), flexor digitorum profundus (FDP), the flexor pollicis longus (FPL) muscles. first three of these muscles are primary wrist muscles. last three are flexors of digits with secondary actions at wrist

Figure 9-13 ■ The dorsally located extensor tendons pass beneath the extensor retinaculum, where the tendons are compartmentalizd. From the radial to the ulnar side, APL, EPB muscles share a compartment; ECRB,ECRL muscles share a compartment (EPL) muscle has a compartment of its own; the four tendons of (EDC) share a compartment with the extensor (EIP) (EDM) and the extensor carpi ulnaris (ECU) has its own compartment

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

Ganglion Cystic structure that arises from synovial sheath Discrete mass Dull ache Dorsal or Volar aspect

Boutonniere Deformity Tear or stretch of the central extensor tendon at PIP Note: unopposed flexion at PIP Extension at DIP Trauma or inflammatory arthritis

Swan Neck Deformity Contraction of intrinsic muscles (trauma, RA) NOTE: Extension at PIP

Osteoarthritis Heberden’s nodes: DIP Bouchard’s nodes: PIP

Rheumatoid Arthritis MCP swelling Swan neck deformities Ulnar deviation at MCP joints Nodules along tendon sheaths

Mallet Finger Hyperflexion injury Ruptured terminal extensor mechanism at DIP Incomplete extension of DIP joint or extensor lag Treatment: –stack splint

Dupuytren’s Contractures Palmar or digital fibromatosis Flexion contracture Painless nodules near palmar crease Male> Female Epilepsy, diabetes, pulmonary dz, alcoholism