WRIST AND HAND
ANATOMY:
Joints:
Distal radioulnar joint.
Radiocarpal joint.
Ulnocarpal joint.
8 carpal bones (proximal and distal row):
Proximal:
Scaphoid, Lunate, Triquetrum, Pisiform(smallest)
Distal:
Trapezium, Trapezoid, Capitate (largest), Hamate
INSPECTION:
Deformity
Attitude of the hand
Color change
Swelling
INSPECTION OF PALMAR SURFACE:
Creases
Thenar and hypothenar eminence
Arched framework
Hills and valleys
Web spaces
DORSAL HAND AND WRIST:
Hills and valleys
Height of metacarpal heads
Finger nails (pale or white – anemia, spoon shaped- fungal infection, clubbed- respiratory or
congenital heart).
Deformity.
Cascade Sign:
Assure all finger point to scaphoid area when flexed at PIPs
PATHOLOGIES
BOUTONNIERE DEFORMITY: (BUTTON HOLE)
Affects the ability to straighten the middle joint of finger tendon at PIP.
Tear or stretch of the central extensor.
Extension at DIP
Trauma or inflammatory arthritis.
SIGNS AND SYMPTOMS:
Pain and stiffness.
CAUSE:
Arthritis, birth deformities.
SWAN NECK DEFORMITY:
Hyperextension at the PIP joint with flexion at the DIP joint.
CAUSE:
Rheumatoid arthritis.
Cerebral palsy.
Stroke
Parkinson.
Trauma.
OSTEOARTHRITIS:
Heberden’s nodes: DIP
Bouchard’s nodes: PIP
MARFAN’S SYNDROME:
Fingers are long(arachnodactyly)
Drop finger or baseball finger.
MALLET FINGER:
At IP joints, flexion deformity at DIP joint which is passively
correctable. Usually caused by minor trauma disrupting the
terminal extensor expansion at the base of distal phalanx, either
with or without bony avulsion.
Injury to the thin tendon that straightens the end joint of finger or
thumb.
SYMPTOM:
Painful.
Swollen and bruised.
DUPUYTREN’S CONTRACTURE:
Contracture of the hand which begins at the
base of the ring or little finger and eventually
pulls them into extreme flexion, making it
difficult to shake hands.
Resulting in MCP and PIP joint of little and ring
becoming fixed in flexion.
SYMPTOMS:
Thickening of skin on palm of hand.
Lump (not painful)
PALPATION:
HARD SWELLING:
Bony outgrowth (osteophytes)
Characteristic of osteoarthritis, mucous cysts or rarely, tumors.
Heberdon’s and bouchard’s nodes occur at DIP and PIP joint respectively.
SOFT SWELLING: synovitis
To detect sponginess –
In IP joints, gently squeezing with your thumb and index finger above and below the joint.
In MCP joint- squeezing gently across the metacarpal joint.
CREPITUS:
place your index finger across the patient’s fully extended fingers and ask to open and close the
finger.
MOVEMENT:
HAND:
To assess active movement; ask the patient to make a fist, then extend his fingers fully. Lack
of full extension of one or more fingers may indicate tendon rupture.
To assess grip, ask the patient to squeeze two of your fingers inserted from the thumb side
into the palm of his hand.
De quervain’s tenosynovitis:
Certain twisting movements like drying and wringing out dish cloths can
cause a localized tenosynovitis of the extensor pollicis brevis and the
abduction pollicis longus tendon.
Tendon swells, movements become painful, firm swelling on the lateral
side of radius just proximal to the wrist.
Tendon sheaths become inflamed and produce a soft creaking sound
on movement.
DIAGNOSIS:
Ask patient to grasp the thumb with other fingers and then push the hand
gently into flexion and ulnar deviation. This stretches the affected tendons reproduce pain.
TREATEMENT:
Eliminating cause of pain.
Steroid injection into tendon sheaths.
Trigger Finger:
A condition where a finger gets struck in a bent position and then
snaps straight. It occurs when the tendon in the affected finger
becomes inflamed.
Clinical features-
swelling on the tendon prevents moving easily
Flexors are stronger than extensors and so tendon gets struck in flexed position.
Extension possible only passively, when it will straighten with a click. This is known as
triggering.
TREATEMENT:
Usually settle with rest and elimination of cause.
Steroid injection into tendon sheath.
Then surgery– if symptoms persist after 3 injections.
TRIGGER THUMB:
Same phenomenon- in thumb- it becomes locked in flexion.
TREATEMENT:
Cured by infection of the tendon sheath with hydrocortisone.
CARPEL TUNNEL SYNDROME:
A numbness and tingling in the hand and arm caused by a pinched nerve in the wrist.
CAUSES:
Pressure on the median nerve.
Fluid retention during pregnancy; goes away after delivery.
Thyroid conditions (hypo thyroidism).
Rheumatoid arthritis.
Diabetes mellitus.
SYMPTOM:
numbness/ tingling in the thumb and next two or three fingers of one or both hands.
Numbness/ tingling of palm of hand.
Pain extending to the elbow.
pain in wrist/ hand in one or both hands.
DIAGNOSIS:
History.
Physical examination-
Tinel sign
Phalen’s maneuver- performed by having the patient place the
wrists in complete unforced flexion for at least 30 seconds. If the
median nerve is entrapped at the wrist, this maneuver reproduces
the symptoms of carpal tunnel syndrome.
Atrophy of the Thenar eminence.
TREATMENT:
Goal- to reduce the swelling and pressure on the median nerve.
Wrist brace.
Avoid inadequate posture and repetitive wrist movement.
SPECIAL TEST:
1.Tinel’s sign
2.Tap test:
The finger-tapping test (FTT) is a neuropsychological test that
examines motor functioning, specifically, motor speed and
lateralized coordination.
Subjects are asked to place their index finger on a key while
their hand rests comfortably on a board. Subjects are then
instructed to tap as fast as possible for 10 seconds
3.Watson clunk:
Also known as the scaphoid shift test, is a diagnostic test for instability between the
scaphoid and lunate bones of the wrist.
The examiner grasps the wrist with their thumb over
the scaphoid tubercle in order to prevent the scaphoid
from moving into its more vertically oriented position in
ulnar deviation.
For the test, the wrist needs to be in slight extension.
The patient's wrist is then moved from ulnar to radial deviation.
The examiner will feel a significant 'clunk' and the patient will experience pain if the test is
positive.
4.Allen test:
The hand is elevated and the patient is asked to clench their fist
for about 30 seconds.
Pressure is applied over the ulnar and the radial arteries so as to
occlude both of them.
Still elevated, the hand is then opened. It should appear
blanched (pallor may be observed at the finger nails).
Ulnar pressure is released while radial pressure is maintained,
and the color should return within 5 to 15 seconds.
If color returns as described, Allen's test is considered to be
normal.
If color fails to return, the test is considered abnormal and it
suggests that the ulnar artery supply to the hand is not sufficient
5.Murphy’s sign:
The Murphy's sign test is used to check for a lunate dislocation.
To perform this test, patient should make a fist with the hand of the
injured wrist.
Assess the contour of MCP joints, if 3rd metacarpal is level with 2nd and 4th
metacarpals, lunate dislocation should be suspected.
6.Phalen’s test.
7.Reverse phalen.
8.De quervain’s test:
Also called Finkelstein test
Bend thumb across palm of the hand and bend other fingers
down over thumb.
Then bend wrist toward the little finger.
Positive- causes pain
