wrist and hand

Question 1

Phalen’s manoeuvre

Answer 1

The symptoms of carpal tunnel syndrome are caused by compression of the median nerve
asitpassesthroughthecarpaltunnelinthewrist. Thissyndromeismostcommoninthe
middle aged and elderly, with over 80% of patients being over 40 years of age.

patient is sitting

The patient is asked to hold their wrist in complete and forced flexion pushing the dorsal
surfaces of both hands together for 30 – 60 seconds (as illustrated below). Ask the patient
if holding this position brings on symptoms (burning, tingling, and numbness) in the hand
and fingers.

Question 2

Phalen’s manoeuvre

explain

Answer 2

This test increases the pressure within the carpal tunnel and can compress the median nerve between the proximal edge of the flexor retinaculum and the anterior border of the distal end of the radius. By compressing the median nerve within the carpal tunnel,
characteristic symptoms (such as burning, tingling or altered sensation) over the thumb, index, middle and ring fingers suggests a positive
test and the presence of carpal tunnel syndrome.
If symptoms only occur after a more prolonged time period, e.g. 60 seconds, this is not necessarily regarded to be diagnostic and may be
regarded as a ‘false positive’ Phalen’s test which will require further investigation.

Question 3

Tinel’s sign

Answer 3

sitting arms supinated on a table

Support the patients’ forearm, and perform a repetitive tapping motion using the tips of your index and middle fingers over the carpal tunnel region at the wrist. The intensity of the tapping should be enough to cause the expected response while avoiding direct irritation of the median nerve. Ask the patient if the tapping brings on
symptoms (burning, tingling, numbness) in the hand and fingers. This is thought to be caused by abnormal mechanosensitivity of the nerve due to compressive effects. Whilst many patients may experience discomfort during the test from the tingling
sensation, a true Tinel’s sign is never painful.

Question 4

Tinels sign

explain

Answer 4

This test increases the mechanical sensitivity of the median nerve within the carpal tunnel.
A positive Tinel’s sign is present when the patient reports a tingling sensation in the distribution of the median nerve (thumb, index, middle
fingers, and lateral aspect of the ring finger over the palmar aspect of the hand)

Question 5

Finkelstein’s test

Answer 5

sitting elboe flexed 90 arm mid pronation

Support the patients’ wrist and hand, then passively take the wrist into ulnar deviation, and the thumb into opposition (passive image). This test can also be
done by asking the patient to actively oppose theirthumb across their palm and make a fist around it with digits 2 – 5, and then to perform full ulnar
deviation of their wrist (active image). Ask the patient if this position or movement reproduces their wrist/thumb pain.

Question 6

Finkelstein’s test

explained

Answer 6

This provocative test increases the mechanical stretch of the tendon sheath of extensor pollicis brevis (EPB) and abductor pollicis longus
(APL) which are situated in the first compartment of the extensor retinaculum at the level of the wrist.
A positive Finkelstein’s test indicates the presence of De Quervains’ Syndrome which is the localised inflammation of this tendon sheath.