Hand and Wrist Examination

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Sequence

Inspection

  • Expose both limbs to the elbow
    • All aspects
    • Don’t forget forearm or ulna aspects
  • Seated, hands on pillow or desk
    • Posture/alignment
    • Tremor
    • Swelling
    • Colour
    • Wasting
    • Scars

Movement

  • Wrist
    • Observe supination/pronation rhythm as you inspect
    • Flexion/extension
    • Radial/ulnar deviation
    • Pronation/supination
  • Fingers
    • Flexion/Extension
    • MCPJs – 0-90°
    • PIPJs – 0-110°
    • DIPJs – 0-90°
    • Abduction/Adduction
  • Thumb
    • Adduction, abduction, opposition, flexion, extension

Palpation

Landmarks

Wrist palpation landmarks.png

Dorsal Wrist Pain

Dorsal-wrist-pain.jpg

A = Intersection syndrome
B = De Quervain’s tenosynovitis
C = Scaphoid fracture / Wartenbergs syndrome (nerve entrapment)
D = Base of thumb arthritis
E = Ulnar collateral ligament injury
F = Carpal boss
G = Scapholunate ligament tear
H = Keinbock’s disease
I = Lunotriquetral ligament tear
J = DRUJ (distal radioulnar joint) arthritis / instability
K = Ulnar impaction / TFCC tear
L = ECU dislocation / tendonitis

Volar Wrist Pain

Volar-wrist.jpg

A = FCU tendonitis
B = Pisiotriquetral arthritis / Ulnar nerve entrapment / ulnar artery thrombosis
C = Hook of hamate fracture
D = Trigger finger
E = Base of thumb arthritis

Special Tests

Special Tests (depends on site of pain, ulnar, radial or mid)

  • Scapholunate instability - Watson test
  • DRUJ instability - Compression/ballotment test, Piano key, Drawer
  • Lunotriquetral instability – lunotriquetral ballotment test
  • Finkelsteins
  • Radiocarpal and midcarpal drawer tests
  • Ulnocarpal stress test
  • ECU subluxation
  • 1st CMC OA – CMC grind test, shuck test, see progressive adduction with hyperextension

Tendons

Neurological Exam

Paediatric Examination

A consensus approach to the MSK examination in children was developed by Foster et al in 2011.[1] The underlined components are those that are additional to the adult examination The italicised components are those that the doctor should be aware of but not necessarily competent in.

  • Look at the hands (palms and backs) for muscle wasting, joint swelling, skin and nail changes
  • Feel for radial pulse, tendon thickening and bulk of thenar and hypothenar eminences
  • Feel for skin temperature
  • Squeeze metacarpophalangeal joints (MCPJs)
  • Bimanually feel /palpate small joints of the hands including wrists and especially if there are swollen or painful joints or restricted movement noted)
  • Look and feel along ulnar border
  • Assess full finger extension and full finger tuck
  • Assess wrist flexion and extension, abduction and adduction  – active and passive
  • Assess function: grip and pinch, picking up small object, writing / drawing
  • Option – hypermobility syndromes, muscle power, capillaroscopy, peripheral nerves

References

  1. Foster et al.. Pediatric regional examination of the musculoskeletal system: a practice- and consensus-based approach. Arthritis care & research 2011. 63:1503-10. PMID: 21954040. DOI.