View source for Musculoskeletal problems of the wrist and hand physical examination

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{{Musculoskeletal problems of the wrist and hand}}
{{CMG}}

== Physical Examination == 
=== Wrist Function ===
* '''Range of Motion'''
** Radiocarpal joint flexion and extension
** Normal  flexion 90°, extension 80°
** Mild pain/stiffness + normal ROM- [[sprain]] or mild [[arthritis]]
** Moderate pain/stiffness + 20% loss ROM-  arthritis
** Severe pain/stiffness + 50% loss ROM-  acute [[gout]], [[fracture]] (navicular/distal radius), [[dislocation]]
** Refusal to move- septic joint, fracture
** Loss of ROM in only one direction (due to pain)
*** Tendon injury or inflammation
*** Pain with passive stretching of [[tendon]] (opposite direction)
* '''Grip Strength'''
** Indirect measure of strength/integrity of forearm muscles
** Can be measured objectively using rolled up partly inflated blood pressure (BP) cuff (patient grip measured in mmHg)
** Reduced grip strength
*** Disuse [[atrophy]], arthritis (hand or wrist), CTS, DeQuervain’s, [[osteonecrosis]]
*** May also be reduced in C8 [[radiculopathy]], severe [[epicondylitis]]

=== Specific Maneuvers ===
* '''Palpation of the Radiocarpal Joint Line'''
*** Junction of distal radius, [[scaphoid]] & lunate
*** At intersection of index finger extensor tendon & distal radius
** Mild tenderness-  simple sprain
** Moderate tenderness-  [[osteoarthritis]] (OA)
** Severe pain- crystal-induced arthritis, Colles’ fracture, scaphoid fracture, perilunate dislocation
** Swelling- mild swelling will fill the depression over the navicular (severe swelling causes a bulge)
** Loss of ROM- significant loss (45° flexion / extension) with advanced disease
* '''Palpation of the Scaphoid Bone'''
** Scaphoid forms floor of anatomical snuff box (distal radial styloid + base of thumb + abductor pollicis longus + extensor pollicis longus)
** Tenderness in anatomical snuff box = scaphoid pathology (fracture, osteonecrosis, arthritis)
* '''Palpation of the Radial Styloid'''
** Pain suggests DeQuervain’s tenosynovitis (friction-induced irritation of anatomic snuffbox tendons)
** Confirmatory testing
*** Pain aggravated by thumb extension or abduction against resistance
**** (Abduction = movement of thumb perpendicular to palm)
*** Pain worse with passive stretch of tendons over radial styloid via thumb flexion
**** (Finkelstein’s test) 
* '''Compression of the Base of Thumb'''
** Screen for CMC arthritis (or strain)
** Pain with compression of the CMC joint in the ante partum (AP) plane suggests CMC arthritis
** Pressure applied from the snuffbox is much less painful
** Swelling best seen with wrist turned radial-side-up
** Crepitation with forcible rotation of metacarpal against trapezium (mortar & pestle sign)
** Bony protuberance of metacarpal or thenar atrophy-  late stages
* '''Palpation of Metocarpophalangeal Joint'''
** Detect gamekeeper’s thumb (ulnar collateral ligament injury)
** Local tenderness/swelling along ulnar side of MP joint suggests diagnosis
** Instability or pain of MP joint with valgus stress (examiner’s thumb at MP joint, index finger at interphalangeal (IP) joint)
** Loss of MP flexion (normal = 90°) and pinch strength can occur with acute symptoms/swelling
* '''Tests for Nerve Compression'''
** CTS
** Sensory loss in the first 3 fingertips-  two-point discrimination, light touch, pain decreased
** Weakness of thumb opposition-  best detected when pt holds thumb + 5th finger together
** Tinel Sign	
*** Vigorous tapping over transverse carpal ligament with wrist in extension
*** Positive if reproduces pain and paresthesia 
** Phalen Sign
*** Both wrists held in extreme volar flexion for 30-60 seconds
*** Positive if symptoms reproduced
** Pronator Teres Compression	
*** If no compression detected at wrist, test for proximal compression
*** Apply pressure to forearm 1 to 2 inches distal to antecubital fossa 
*** Positive if symptoms reproduced with compression
*** Sensitivity increased by resisting forearm pronation
** '''Note-''' Tests can be totally normal despite significant compression (symptoms vary over time)
*** Sensitivity and specificity of provocative tests low
* '''Transillumination'''
** Distinguishes between ganglion (transilluminates) and solid mass
** Ganglion cyst should be highly mobile and fluctuant, not adherent; ROM should be full
** Aspiration of cyst yields thick, colorless fluid

== References ==
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[[Category:Disease]]
[[Category:Musculoskeletal Disease]]
[[Category:Needs overview]]