Hand and Wrist Examination, Dr. Michael Garcia

Pleasure to be back here speaking with you all again. And my topic is going to be a review for a lot of you guys and gals but it may also show in a little bit more specificity some of the special exams that we do for the hand and wrist to review of the pertinent sort of physical exam anatomy and highlight really the importance of using your eyes and your ears to evaluate patients because the majority the hand and wrist examination if you were to go through an entire Hand and wrist examination on every patient that came over the hand complaint you’d be the be in there for 30 minutes. We have so many different tests we can do but by using the history and using clues and observing the hand you can really pare it down to the very specific area of pain or discomfort and really develop a very quickly a short list of differential diagnosis that you can use to further the treatment of the patient.
So some disclosures I am a consultant for arthritis for Endo Pharmaceuticals and for Axon but I’m not receiving financial compensation for this talk. So we’re gonna talk about the hand physical exam like we talked about any physical exam of any other organ system. We’re going to break it down into the different sort of aspects of the exam. So as you go through it you can develop an efficient manner in which you can examine the hand and really develop a technique that’s unique to your own. So you can be complete and thorough and hit a lot of not only important topics and in organ systems for billing. But also to make sure that you don’t miss anything that may be a subtle finding on the exam. Time to go through observation vascular exam, neurologic exam, the skeletal RANGE MOTION exam, tendons and soft tissues, and then ultimately we’re going to discuss special test of which there is a myriad of special tests for different sort of pathologic conditions.
So first off some general nomenclature we have our own kind of language when we talk about the hand. And it’s a fairly specific we don’t talk about medial and lateral when we talk about the hand we talk about radial and owner the thumb side being the radial side the owner side being the small finger side.
When we discuss the sides of the hand the back of the hand is the dorsal surface of the hand or the extensive surface of the hand and the palm or surface of the hand is called the vole or surface of the hand. I don’t know what a vole is but I know what a palm is. But nonetheless we still call it the vole or surf surface the hand. I sure do know what a vole is because I looked it up it’s a small little marsupial mammal that’s kind of ugly it looks like a miniature possum and we don’t call it the digits by numbers. We leave that to the Foot and Ankle Surgeons because other than the big toe the lesser toes don’t really matter that much so we can just No them but the fingers are important so we named them. And so it’s the thumb the index the long Don’t say middle because middle sounds like little.
And that can be very confusing particularly when you’re when you’re dictating a note as in the transcription is stuck can mess up middle and little so we say long instead of middle and we say ring and then small instead of little because of the. Again the similarity and sounding of the two fingers. And then when we’re talking about the joints, we talk about the proximal the proximal portion or the phalanges excuse me we talk about the proximal phalanges the middle flange in the distal phalanges and then the joints of the proximal interphalangeal joint in the distal interphalangeal joint. And where we abbreviate or shorten those, we do not call them pips and dips we call them PIPs and DIPs. very rapidly when you’re talking to a hand surgeon and if you call somebody a pip then they begin to become very suspicious of what you’re talking about because they know that you may not be very knowledgeable about the hand and specifics and again it’s essential to obtain a good history in these patients.
So the physical exam starts with the chief complaint and that can help you pare down the complaints a lot of times people come in and say My hand hurts and what I’ll ask him as I say point to where it hurts the most because most people will kind of wave their hand diffuse slowly over the back of the front of their hand showing you where they think that it hurts but if you get them to actually point exactly to where it hurts you can really hone in your physical exam into that area there are conditions that do radiate in the hands and risk but they often begin at a very specific location and if you can learn the surface anatomy and learn to make out in the patient and help you with that by pointing to their location of a discomfort it would be very helpful.
And you have to have a system it’s a long exam. It’s an arduous exam there’s a lot of details that you have to document and so without a system you’ll be lost. So again, observation is incredibly important. So we can look at a hand and say Is it viable does it look pink does it look warm up refused.
Is there some sort of vascular injury causing disvascularity an appearance of either congestion with a blue hand or lack of inflow from the artery which can lead to a white hand? Is there atrophy of the muscles that can be a big as to what type of neurologic condition that they’re suffering from? Is there swelling or edema? Often a sign of acute trauma or infection as is in this picture here you can see that everything in this area and between the second web space with the fingers splayed like this is is very typical of a collar button abscess. You don’t even have to really lay your hands on this patient you can look at a picture of this patient. You can look at a look at this patient’s hand and you can know almost immediately that this is an infectious process that requires surgical intervention. Does the hand sit in a normal position you know we can all kind of sit with our hand completely relax with our palm up to the air and we can see that our hand and fingers sit but certainly a certain position what we call a cascade or tenodesis and it does a hand sit like that is one finger sitting directly straight or is one finger drooping or not extending and that can be a clue to attend an injury.
Does the skeletal appear as stable as the hand and wrists sitting in a position that is not anatomic compared to their control outside. And that brings me to probably the most important part of the physical exam is to examine the normal uninjured or non-complaining side. If you examine that side to see what this patient’s typical hand appearance looks like it will often very rapidly clue you in as to where to look for the hand the hand a physical exam.
Next, we can assess vascular to the hand. So we do that to examination of the skin is the skin warm and well refused. Does it have the appropriate sort of a trigger? Does it have normal capillary refill is the temperature the same as a control outside? If there are lacerations and there’s concern for an arterial injury, we can pop a pulses. We can test the pulses with proximity in distantly and in the finger if you have access to a Doppler probe you can do Doppler that you can Doppler out the digital arteries which is actually very simple to do along the borders of the finger and you can hear a triphasic pulse distal to the laceration you know you have a pretty good chance that the laceration did not involve the artery and then you if you’re concerned about the continuity of the arch which the particular superficial arch which supplies the majority of the blood supply to the hand. You can perform an Allen’s test now in is performed by including the radial on an artery at the wrist of squeezing their risk pretty tightly always in the patient’s arms squeezing pretty tightly and have the make of typeface and release and if you guys want to practice this on each other you can you can see that very rapidly the hand will blanch and turn white and then you can release in sequence in sequence the arteries to find out if the artery at the radial or an artery is supplying the entirety of the hand indicating a complete arch.
Then we examine the neuro sensory exam the nerve sensory exam is A very common organ system to complain about in the upper extremity. Very often people come in with pain numb pain and numbness and tingling in their hand and so knowing the anatomy of the neuro sensory portion of the hand and also knowing how to examine that is very important so that we can determine if there is some element of compressive neuropathy diabetic polyneuropathy other sort of reason for their numbness entangling. Light touch is often adequate for this you don’t have to do any specific special tests if you need to do a specific special test or we feel that it’s warranted two-point discrimination test is very easy to do and it can be done with a paperclip. You just unbend the paperclip to about five millimeters apart with the with the two points of the paperclip and then you can use that as a two point discriminator and normal two point discriminator is and between four to six millimeters in the tips of the fingers and it can go up to ten in some people with some element of neuropathy in the fingers.
Anything higher than ten is usually indicative of a significant nerve injury.
The issue at two-point discrimination is it’s a late finding that it tests sensory innovation density so you require some element of atrophy of that of the end organs of the nerve in the fingertips prior to seeing significant changes in two-point discrimination. A more specific test would be a Semmes Weinstein filament test although that requires special apparatus to perform but it can be a very specific exam determining the level and depth of their sensibility.
Remember the median nerve integrates the radial side of the hand the thumb index middle and half of the ring finger and also the palm but also remember that the Palm sensation is a branch of a nerve that exits the median nerve prior to entering the carpal tunnel.
So patients with carpal tunnel syndrome should have a normal sensate palm and they should have a decreased sensation or poor sensation in the digits if they have Palmer lack of sensation or Palmer numbness and tingling Then you have to consider potentially a more proximal lesion. The honor nerve is the underside of the hand and half of the small finger typically seen in cubital tunnel syndrome the radio nerve innovates the back of the hand in the first webs space. Now when we examine the motor skills motor function in the hand, we like to examine the distal most innovative muscle and for the median nerve that’s the abductor pollicis brevis.
Remember that the median nerve innervates the two loaf muscles so two radial lumbricals the opponens pollicis and the abductor and the flexor pollicis brevis. In the test who ask the patient to bring the thumb up out of the palm of the hand and resist you. This is often something that requires a little bit of coaching for the patient because it’s kind of an odd motion for the patient to isolate this abduction. So what I usually do is I place my finger in the location that I want the patient to touch and then I’ll have them bring the thumb to my finger and I’ll say resist me and then that’s how I resist that. That’s the easiest way to do that if you just show the patient to do that oftentimes they’ll be confused. The owner nerve innervates the hypothenar muscles or the muscles in the small finger side of the hand the inner and the owner two lumbricals and also the abductor pollisis in the deep head of the flexor pollicis previous.
And you can examine this muscle by having the patients either cross their fingers over both you know the index over the middle in the middle over the index and you can also test the strength by having them spread their fingers apart and test the strength of the of the interaction muscle. A classic physical exam findings someone with all neuropathies are from inset test where you have the pinch with a flat thumb against their index finger a piece of paper and if they have weakness of the editor pollicis an owner innervacte in muscle they will supplement holding that piece of paper with their flexor pollicis long as which is immediate integrated in their muscle and that’s a positive from inside. The radial nerve we test by testing the EPL or extensor pollicis longusat the EPL extends the IP joint but its main function is actually to retro pulse the thumb.
So what that means is with the palm flat on the table they can bring the thumb up off the table and that’s that indicates an intact EPL. You can fake someone out with your other muscles around the thumb for extending the IP joint but you can’t read your post of thumb without an EPL.
So remember we talked about that tenodesis effect in the general hand posture so you can just sit and observe the hand with its supinaded and relaxed and should kind of sit in a position like this and you can all kind of just sit there and do that at your at your table and see that this is indeed the case without attendant injury. This is relative to the tenodesis effect which is the effect of a tendon at a joint just due to the tension within the muscles crossing that joint in order to test the flexor tendons. You have to isolate the flexor tendons because there’s two flexor tendons each to teach finger the FDS and the FDP isolating the FDS you do by holding the other digits that you’re trying to get them to not extend extended and then you have them flex the non the non-blocked digit at the PIP joint. And oftentimes this requires an exam from the physician to get them to do it but this will isolate the FDS this is due to the common muscle belly of the FDP tendon in the forearm.
With that and it’s hard to individually activate the FDP when they’re held in an extended posture. The FCP test is a little bit easier. You immobilize the middle phalanx and you have them flex the DIP joint against resistance and do these against resistance because partial lacerations can present with weakness as opposed to an inability to move the joint through that motion. The FPL test is the same as the FDP tests but to the flexor of the thumb. FCR FCU you can be tested by Palpating the tendon with resistant risk flexion and most of our patients that aren’t too obese you can actually see most of the tendon structures at X flex and extend the wrist at the level of the risk crease and so just having them flex against resistance allows you to power pain and feel those. APL and EPB you can have them extend the thumb in the plain of the hand against resistance and then EPL again retro passes the thumb extends her tendons go back to the last line excuse me how do I go back.
So the EDC tendons. So we kind of have a design fall the way the extensive mechanism works in the back of the hand and often postures a very good examination for this but because one tendon extends three joint you really have to have them hyper extend the MCP joints kind of like a bear claw in order to evaluate the integrity of that of that tendon proximal to the digits and the EIP and EDM which are the individual extensions to the to the index and a small finger have them extend the index and small finger with the ring and middle ring and long finger flex into the palm. Remember that extensive tendons are interconnected in the back of the hand through the gentry and this can often lead to a confusing physical exam of a patient that you’re certain has cut their extensive tendon but it appears to be intact when they go to actively extend it. They’re extending through the junk jury but often this extension will be weak or an incomplete and they’re unable to hyper extend at the MCP joint.
That’s why it’s important to have to make that bear paw position. And then again the thenar and hyperthenar muscles are examined by testing their muscle bellies. In the skeleton observation and palpation is key to the skull exam. If you see a patient coming in with a finger that’s pointed in the wrong direction or wrist that’s kind of cocked off into the wrong direction it’s pretty obvious that they have an issue with their skeletal exam but palpation is also very important in two places to play that are very important are the snuff box and the snuff box tenderness can indicate which is indicated by the photograph there can indicate a fracture to the scaphoid and tenderness there should be treated with the immobilization. And the dorsal ulnar carpus it can indicate a trifle avulsion fracture which should be immobilized and difficult to see on the x rays.
I remember radiographs are an important part of the skull to physical exam in one view is no view. If you only have one view and you do not have two views orthogonal to each other you will miss injuries and so make sure that you get good 90-degree x rays to include in your in your assessment of the patients. Again look for abnormal drawing motion have the move the other extremity and see if it moves in a similar congruent manner and test the stability and the integrity of the of the collateral ligaments particularly in areas that they’re painful as significant laxity as measured through the mid axis of the digit is often indicative of a need for a a hand surgery referral. Specialty tests are very important to the hand an upper extremity physical exam and it’s important to assess specific anatomical particle pathologic lesions.
They’re very user and patient dependent so its practice is really what makes perfect with these and so I always tell the residents and fellows in England that I’m training or talking about this to perform normal to form these physical exam tests a normal risk so that you can get kind of your library of what normal is because there is a large variance in the patient population. The most common specialty tests we do in the upper extremity of the test for compressing or apathy. There’s Phalens test which is a reflection of the risks and not about 90 or maximal flexion for at least a minute. They have to have known I’m sitting in developed with the minute to consider that it’s negative. This often leads to a lot of awkward conversations as you’re sitting there waiting for the patient to pass the minute mark and staring longingly into their eyes to determine if they have carpal tunnel syndrome.
Now this test has actually developed to determine whether or not a nerve is regenerating after repair it’s not a perfect test for compressing rapidly but it can still be positive both at the elbow for cubital tunnel syndrome and at the risk for carpal tunnel syndrome darkens maneuver is what I often use and has been shown to be the most specific insensitive when augmented with the failings test where you just basically compress the median nerve of the carpal tunnel just like you do at an elbow flexion test or an augmented the above flexion test when you compress the owner nerve at the cubicle tunnel with the elbow flexed. Here’s some pictures this is the elbow flexion test and usually I will often put pressure on the owner nerve in that area to expedite kind of any physical exam findings. The Durkins tests doing compression at the carpal tunnel and I’ll often augment that with reflections incorporating a failing state maneuver and then fail and test there with the wrist flexed against each other.
Now remember. Patients have a hard time describing where their hand is numb. So if you have their elbows hyper flexed in their wrist hyperflexed against each other they say that their hand is numb. That’s probably not enough because they may be indicating that from the elbow flexion position that they’ve developed some ulnar nerve symptoms so make sure you query them as to exactly what they’re describing when they describe the numbness Finkelstein’s test is for de quervain’s tenosynovitis which istenosynovitis the first dorsal compartment or paint over the radial styloid. You have them grasp their thumb with their wrist and then only deviate the wrist and that will cause pain of the radial styloid. To be honest we do this to yourself right now you can notice that it’s not that comfortable on yourself so have them make sure they do it on the non non injured side to assure that it is indeed significantly more painful.
Truly if someone has real deck or veins and you do this now grab the wrist and only deviate them with their thumb in their palm. They are going to want to punch you because it is very very painful. The all these are ads since test or the CMC grind test is a good test for CMC arthritis where you hold the thumb actually load it at the metacarpal and then you actually load the CMC joint and that should cause pain and crepitus for patients with CMC joint osteoarthritis. Watson shift test is a test for carpal instability where you push on the skateboard to tuber cone you try to basically push the scaphoid tuberacle the back of the wrist. If they have a skiffle innate ligament tear this test is very very difficult to create a positive elicit a response in the clinic and ask the patient but in the operating room we can often get a positive clunk so that people can feel what that kind of feels like the shock and she shook her sheer test can be done anywhere in the hand and rest is where you basically take two bones that you’re concerned about instability and you shear them against each other to see if they can if they elicit pain or if you can feel instability phobia tests for the TFCC.
Basically push volar to the owner styloid at the wrist on the underside of the wrist and you just push in there and that’s right where the insertion of the of the FCC is in the wrist and if that elicits pain they often have some sort of TFCC pathology in the live test is is another pretty simple test to do if you’re worried about owner side of his pain which is a talk all in and of itself where you supersede the patient’s hands and you have them tried to lift the table or the desk off the ground and that will elicit pain on the owner side of the wrist but Nell’s test and X is a test for intrinsic tightness and there’s an extrinsic tightness test. I’d be happy to talk about you these after the talk I’ve gotten a little bit over and these are pretty complicated.
These are more and more very specific tests for what may lead to a loss of active range of motion the digits. So in conclusion a thorough examination of the universe is key but history is more important so that you can hone in because as you can see that is a very large topic and a very large exam to cover and a patient visit and assess all parts of the hand and risks involved with that pathology and try to apply some specialty test for that area to get a more specific diagnosis and observe first and compare to the control outside. And if you do that then I think you’ll be successful. Thank you.