Hand and Wrist Examination

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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
  • Note any hypermobility and skin hyperextensibility.

Palpation

Assess landmarks for tenderness, swelling (ganglions, dactylitis, synovitis, bone or soft tissue), temperature, vasomotor, and sudomotor changes.

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
  • Lunotriquetral instability – lunotriquetral ballotment test
  • DRUJ instability - Compression/ballotment test, Piano key, Drawer
  • De Quervain - Finklesteins and Eichoffs for
  • Carpal Tunnel Syndrome - Phalens and Tinels
  • 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.