Wrist and Hand

Question 1

Active ROM

Answer 1

Wrist

• Flexion (85-90°)
• Extension (70-90°)
• Ulnar deviation (30-45°)
• Radial deviation (15°)
• Pronation (90°)
• Supination (90°)

Finger

• Flexion (MCP 85-90°, PIP 100-115°, DIP 80-90° )
• Extension (MCP 30-45°, PIP 0°, DIP 20°)
• Abduction (20-30°) and Adduction (0°)

Thumb

• Flexion (CMC 45-50°, MCP 50-55°, IP 85-90°)
• Extension (MCP 0°, IP 0-5°)
• Abduction (60-70°) and adduction (30°)
• Opposition of little finger and thumb

Question 2

Passive ROM

Answer 2

Wrist

• Pronation and supination (tissue stretch)
• Flexion (tissue stretch)
• Extension (tissue stretch or bone-to-bone)
• Ulnar and radial deviation (bone-to-bone)

Finger

• Flexion and extension (tissue stretch)
• Abduction and adduction (tissue stretch)

Thumb

• Flexion and extension (tissue stretch)
• Abduction (tissue stretch) and adduction (tissue approximation)
• Opposition (tissue stretch)

Question 3

Fanning and Folding of the Hand

Answer 3

Purpose

• To assess conjunction rotation of the hand

Procedure

• The examiner holds the scaphoid and trapezium with the index and middle finger of one hand and the pisiform and hamate the index and middle finger of the other hand
• The practitioner holds the patient’s capitate and trapezoid with their right and left thumbs on the dorsum of the hand
• The examiner folds and fans the hand, feeling the movement while monitoring and feeling for crepitus and joint motion

Indication of positive

• Symptom reproduction or abnormal moving of shifting of joints is an indication of a positive result

Clinical note

• The test is used as a general screening examination, not to identify a specific pathological condition

Question 4

Finkelstein Test

Answer 4

Purpose

• To assess for irritation of the extensor pollicis brevis and abductor pollicis longus tendon as they pass deep to the extensor retinaculum in the first dorsal compartment in the wrist

Procedure

• The patient is asked to make a fist with the thumb inside the fingers
• The examiner stabilizers the patient’s forearm with one hand and then passively ulnar deviates the patient’s wrist while keeping the patient’s thumb enclosed in the fist

Indication of Positive

• Pain or reproduction of symptoms over the abductor pollicis longus and extensor pollicis brevis tendons at the wrist is a positive test result and indicates a paratendonitis or tendinosis of these two tendons

Clinical Note

• Because the test can cause some discomfort even in normal individuals, the examiner should compare the pain caused on the involved side with that on the unaffected side
• The test result is considered positive only if greater pain or symptom reproduction is noted on the affected side

Question 5

Tinel’s Sign: Wrist

Answer 5

Purpose

• To assess for median nerve involvement at the carpal tunnel of the wrist

Procedure

• The examiner supinates the patient’s hand and wrist and stabilizes the forearm with the secondary hand
• The primary hand is used to tap along the median nerve pathway
• The examiner taps over the carpal tunnel at the wrist with the index and middle finger, working up the arm and following the path of the median nerve

Indication of Positive

• A positive test result is indicated by tingling or paraesthesia into the thumb, index finger (forefinger), and middle and lateral half of the ring finger (median nerve distribution)
• For a positive test result, the tingling or paraesthesia must be felt distal to the point of tapping

Clinical Note

• The test gives an indication of the rate of regeneration of sensory fibres of the median nerve
• The most distal point at which the normal sensation is felt represents the limit of nerve regeneration
• The manoeuvre can be applied at any of the common entrapment sites in the wrist and hand

Question 6

Phalen’s (Wrist flexion) Test

Answer 6

Purpose

• To assess for median nerve involvement through the carpal tunnel of the wrist

​Procedure

• Patient is sitting or standing
• The patient flexes the wrist maximally and then presses the dorsum of the hands together
• The patient then holds this position for 1 minute

Indication of Positive

• A positive test result is indicated by tingling in the thumb, index, middle and lateral half of the ring finger
• A positive test is indicative of carpal tunnel syndrome caused by pressure (compression) in the carpal tunnel

Clinical Note

• Tests for neurological dysfunction are highly suggestive of a particular nerve lesion if they produce a positive result, but they do not rule out the problem if the results is negative. In fact, tests results may be negative 50% of the time or more often even when the condition actually exists. Electrodiagnositc tests are more conclusive.

Question 7

Carpal Compression Test

Answer 7

Purpose

• Part I: This test is a pressure provocation test over the carpal tunnel to assess for median n. involvement
• Part II: This test is a pressure provocation test over the Tunnel of Guyon to assess for ulnar n. involvement

Procedure

• Part I: The practitioner applies direct thumb pressure over the carpal tunnel for up to 30 seconds
• Part II: The practitioner applies direct thumb pressure over the Tunnel of Guyon for up to 30 seconds

Indication of Positive

• Reproduction of the patients symptoms if combined with relief when the pressure is released
• Paraesthesia in the associated n. distribution

Question 8

Reverse Phalen’s Test

Answer 8

Purpose

• To assess for median nerve involvement through the carpal tunnel of the wrist

Procedure

• The patient is standing or sitting
• The patient is asked to put the palms of the two hands together and bring the hands down towards the waist while keeping the palms in full contact (prayer test), thus causing extension of the wrist
• This position is held for approximately 1 minute

Indication of Positive

• A positive test result is indicated by tingling in the thumb, index, middle and lateral half of the ring finger
• A positive test is indicative of carpal tunnel syndrome caused by stretching the median nerve

Question 9

Allen Test

Answer 9

Purpose

• To assess the patency of the ulnar and radial arteries and to determine which artery is providing the main blood supply to the hand

Procedure

• The patient is asked to open and close the hand quickly several times and then to squeeze the hand tightly so that the venous blood is forced out of the palm
• The thumb of the practitioner’s primary hand is placed over the radial a. and the thumb of the secondary contact are placed over the ulna a. and they press the arteries against the underlying bones with the aim of occluding the arteries
• With the arteries still occluded the patient is asked to open the hand, the palm should be pale and white
• One artery is tested by releasing the pressure over the artery while keeping the pressure on the other artery
• The procedure is then repeated with the other artery being released first

Indication of Positive

• Normally, after releasing one artery the hand should flush immediately
• If it flushes slowly or not at all the artery may be partially or totally occluded
• The same situation should occur when the other artery is released

Clinical Note

• Both hands should be tested for comparison
• The test limb can be held in an abducted position in the initial phase of the test to maximise the circulatory block

Question 10

Digital Blood Flow (Perfusion) Test

Answer 10

Purpose

• To determine the patency of the digital arteries in the fingers

Procedure

• The examiner compresses the nail bed and then releases it and notes the time taken for colour to return to the nail
• Compare to normal side

Indication of Positive

• Normally, colour should return to the nail bed within 3 seconds
• If return takes longer, it may indicate possible arterial insufficiency to the fingers

Question 11

Fovea Sign

Answer 11

Purpose

• A provocative manoeuvre for the assessment of disassociations of the distal radio-ulnar ligaments from the fovea region of the ulnar head or injury to the ulnocarpal ligaments
  
  • Ulnotriquetral lig.
  • Ulnocapitate lig.
  • Ulnolunate lig.
  • TFCC tear

Procedure

• Patient sitting with the elbow on the table and arm flexed to 90°-100° and forearm in neutral
• The practitioner pushes their thumb into the soft spot between the ulnar styloid, and the flexor carpi ulnaris tendon, volar surface of the ulna head and the pisiform

Positive

• Exquisite tenderness compared to the contralateral side
• Replication of the patient’s complaint/symptoms
• Facial grimacing

Indication of Positive

• Dysfunction of the distal radio-ulnar ligament or the ulnocarpal ligaments or the TFCC

Question 12

TFCC Load Test

Answer 12

Purpose

• ​To assess the integrity of the TFFC in the wrist

Procedure

• The examiner stabilisers the patient’s wrist by contacting the patients hand with the primary contact in a ‘handshake’ position
• The examiner stabilises the patient’s elbow with the secondary contact
• The practitioner passively ulnar deviates and applies an axial load through the patient’s wrist
• The wrist may also be rolled from flexion to extension while maintaining ulnar deviation which is referred to as ‘grinding’ or ‘scouring’

Positive

• Pain, clicking, crepitus in the area of the TFCC

Indication of Positive

• Disruption of the TFCC

Question 13

Finger Extension (‘Shuck’) Test

Answer 13

Purpose

• General screening tool for wrist/hand pathological
• Radiocarpal instability
• Midcarpal instability
• Scaphoid instability
• Inflammation
• Keinbock’s Disease

Procedure

• The examiner holds the patient’s pronated wrist in approximately 45° of wrist flexion
• The examiner contacts the patient’s metacarpals and asks the patient to actively extend the wrist and hand against resistance

Positive

• Pain
• Possible radiocarpal, midcarpal or scaphoid instability
• Possible inflammation
• Possible Kienbock’s disease

Question 14

Watson (Scaphoid Shift) Test

Answer 14

Purpose

• To asses the integrity and stability of the scapholunate joint:
  
  • Scapholunate lig. sprain/tear
  • Scapholunate joint instability
  • Scapholunate joint subluxation

Procedure

• The patient places their flexed elbow on the table with their palm facing the practitioner
• The examiner contacts over the patient’s metacarpals with the secondary contact, and creates full ulnar deviation and slight extension at the wrist
• The examiner then contacts the patient’s scaphoid with the primary hand using a pincher grip with the thumb over the volar scaphoid
• The practitioner then applies slight A-P pressure to the volar scaphoid while radially deviating and flexing the patient’s hand over the thumb contact

Positive

• Dorsal scaphoid shift on flexion and a ‘clunk’ on release of the thumb contact
• Indicating scapholunate instability

Question 15

Lunotriquetral Ballottement Test

Answer 15

Purpose

• To assess the integrity of the and stability of the lunotriquetral joint:
• Lunotriquetral lig. sprain/tear
• Lunotriquetral joint instability
• Lunotriquetral joint subluxation
• Distal Radio Ulnar Joint (DRUJ) instability

Procedure

• The examiner grasps the triquetrum with the thumb and index finger of the primary hand and grasps the lunate between the thumb and index finger of the secondary hand
• The examiner then moves the lunate P-A and A-P while stabilising the triquetrum

Positive

• Laxity, crepitus and pain
• Indicating lunotriquetral instability
• Indicating DRUJ instability if performed at the DRUJ

Question 16

Dorsal Capitate Displacement Apprehension Test

Answer 16

Purpose

• This test is used to assess the stability of the capitate bone

Procedure

• The examiner holds the patient’s distal forearm in neutral with the secondary hand
• The practitioner contacts the patient’s capitate using a pincher grip with the primary hand (thumb on the volar surface of the capitate and the fingers stabilising the dorsal capitate)
• The primary thumb contact pushes the capitate posteriorly

Positive

• Reproduction of symptoms, pain or apprehension
• The examiner notes if a click occurs
• Indicates capitate instability

Question 17

Thumb: Valgus/Varus Stress Test

Answer 17

Purpose:

• To assess the integrity of the ulnar and radial collateral ligaments of the MCP joint of the thumb:
  
  • 1st MCP ulnar collateral lig. injury: accessory and/or proper portions
  • 1st MCP radial collateral lig. Injury: accessory and/or proper portions

Procedure:

• Part I:
  
  • The practitioner stabilises the patient’s hand at the 1st metacarpal using a pincher grip with the secondary contact
  • The practitioner holds the patient’s 1st MCP joint in 0° extension and applies valgus stress to the MCP joint with the primary contact
  • The test is then repeated with the thumb flexed to 30°
• Part II:
  
  • The practitioner stabilises the patient’s hand at the 1st metacarpal using a pincher grip with the secondary contact
  • The practitioner holds the patient’s 1st MCP joint in 0° extension and applies varus stress to the MCP joint with the primary contact
  • The test is then repeated with the thumb flexed to 30°

Positive:

• Laxity with or without pain
• Empty end feel

Indication of a Positive:

• Laxity greater than 30-35° = complete tear
• Laxity less than 30-35° = partial tear (usually with pain)
• Varus/valgus testing in extension tests both the joint capsule and the collateral ligaments
• Flexion of the MCP joint localises the test to the collateral ligament (both ulnar and radial)

Question 18

Finger: Valgus/Varus Stress Test

Answer 18

Purpose:

• To assess the patency of the collateral ligaments of the MCP and IP joints of the fingers:
  
  • Collateral lig.sprain
  • Avulsion fracture

Procedure:

• Part I:
  
  • The practitioner stabilises the patient’s finger proximal to the joint being assessed with the secondary contact
  • The patient’s MCP joints should be in flexion when assessing the IP joints
  • With the primary contact the practitioner applies a valgus force while the joint is held in a fully extended position
• Part II:
  
  • The practitioner stabilises the patient’s finger proximal to the joint being assessed with the secondary contact
  • The patient’s MCP joints should be in flexion when assessing the IP joints
  • With the primary contact the practitioner applies a varus force while the joint is held in a fully extended position

Positive:

• Laxity with or without pain
• Empty end feel

Indications of Positive:

• Collateral lig. Injury
• Avulsion fracture

Clinical note:

• The tests should be performed in varying degrees of flexion to test different aspects of the collateral ligaments
• Ideally the finger should be tested at 0 and 30 degrees of flexion

Question 19

Profundus Test

Answer 19

Purpose:

• To assess for disassociation of the flexor digitorum profundus from the distal phalanx

Procedure:

• The practitioner holds the patient’s affected finger (MCP and PIP joints) in extension
• The other fingers should be flexed at the MCP and PIP joints
• The patient is then asked to flex only the DIP joint of the affected finger

Positive:

• Inability to flex the affected DIP joint

Indication of Positive:

• Rupture of flexor digitorum profundus

Question 20

Sweater Finger Sign

Answer 20

Purpose:

• To assess for disassociation of the flexor digitorum profundus from the distal phalanx

Procedure:

• The patient is instructed to make a fist
• The practitioner observes for the patient’s inability to flex the affected finger into the fist shape

Positive:

• An inability of the patient to flex the distal interphalangeal joint

Indication of Positive:

• Rupture of the flexor digitorum profundus tendon from the distal phalanx

Question 21

Superficialis Test

Answer 21

Purpose:

• To assess for disassociation of the flexor digitorum superficialis from the middle phalanx

Procedure:

• The practitioner holds the patient’s unaffected fingers in extension
• The patient is asked to flex the affected finger

Positive:

• Inability to flex the affected PIP joint

Indication of Positive

• Rupture of flexor digitorum superficialis

Question 22

Test for Extensor Hood Rupture

Answer 22

Purpose:

• To test the integrity of the extensor hood

Procedure:

• Patient is sitting with the pronated forearm resting on the table
• The PIP joint of the finger to be examined is flexed to 90° over the end of the examining table or a thick textbook
• The practitioner firmly holds the patient’s finger in this position by contacting distal to the PIP joint on the patient’s middle phalanx
• From this position the patient is asked to gently extend the finger at the PIP joint againstresistance

Positive:

• The practitioner is unable to feel or feels minimal extension force acting to move the middle phalanx
• The distal phalanx does not remain flail and may extend as the patient attempts to extend the finger from the PIP joint

Indication of Positive:

• Complete rupture of the central slip of the extensor mechanism

Clinical Note:

• Long standing central slip rupture will present as a Boutonierre Deformity
• Also known as Elson Test

Question 23

Bunnel-Littler Test

Answer 23

Purpose:

• To assess for potential causes of limited PIP joint flexion
• Can be used to examine individuals with swan neck deformity

Procedure:

• The MCP joint of the affected finger is held in extension
• The examiner attempts to passively move the PIP joint of the affected finger into flexion
• If the PIP joint is unable to flex the examiner then slightly flexes the MCP joint and again tries to flex the patient’s PIP joint
• The patient remains passive throughout the procedure

Positive:

• Inability to flex the PIP joint with an extended MCP joint indicates contracture of the PIP joint or tight intrinsic muscles of the hand
• Inability to flex the PIP joint with the MCP slightly flexed indicates PIP joint contracture

Question 24

Test for Trigger Finger

Answer 24

Purpose:

• To assess for nodules or thickening of regions of the flexor tendons in the hand

Procedure:

• The examiner grasps the patient’s affected finger with a pincher grip with the index finger or thumb over the location of the proximal pulley
• The patient then flexes their finger over the examiner’s contact

Positive:

• The examiner may feel a small nodule pass beneath their fingers with the patient complaining of pain

Indication of Positive:

• Stenosing Tenosynovitis (Trigger finger)
• Early stage Dupuytren’s Contracture