Procedure 1 Examination of the Hand and Wrist

See Video 1: Clinical Examination of the Hand and Wrist

“No organ, anatomical structure, or laboratory procedure can reveal as much practical information about a patient as can the hand.”

Bruce W. Conolly, 1980

Figures 1-42 and 1-43 are from Chung KC, Yang L, McGillicuddy JE (eds). Practical Management of Pediatric and Adult Brachial Plexus Palsies. Philadelphia: Elsevier; 2011.

Man depends on his hands for work, recreation, and expression. The hand not only reflects emotional and physical character but also is a mirror of underlying systemic disease. An understanding of the basic functional anatomy of the hand is essential for examination, accurate diagnosis, and successful treatment of disorders of the hand. Standard terminology should be used when describing the anatomy and motion of the hand and wrist. This avoids confusion and compromised patient care when the pathology is described to colleagues.

The human hand consists of a broad palm with five digits, attached to the forearm at the wrist joint. The five digits include the thumb and the four fingers, namely the index (IF), long (LF), ring (RF), and small finger (SF) (Fig. 1-1). The long and small fingers are often called the middle and little fingers, respectively. We believe that the term long finger is more appropriate to avoid the ambiguity as to what constitutes the middle finger. The use of little finger and long finger confuses their acronyms (LF); hence, small finger is preferred.

FIGURE 1-1

The hand has two surfaces—dorsal and palmar. The use of the term palmar should be restricted to the area limited by the glabrous skin, and the term volar should be used for areas proximal to it (see Fig. 1-1). Radial is used to describe direction toward the thumb and ulnar to describe direction toward the small finger, rather than lateral and medial (see Fig. 1-1). The palm has two eminences: the thenar eminence, which contains the intrinsic muscles of the thumb; and the hypothenar eminence, which contains the intrinsic muscles of the small finger (see Fig. 1-1). The connotation of the word intrinsic is to describe muscles that originate and insert in the hand, whereas extrinsic indicates muscles that originate outside the hand, such as the extrinsic finger flexors. The three well-defined creases of the hand are the thenar crease (forms the boundary of the thenar eminence), the proximal and distal palmar creases, and the distal wrist crease (forms the boundary of the glabrous skin) (see Fig. 1-1).

Each finger has three phalanges, namely proximal, middle, and distal, and three joints, namely metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP). The thumb has two phalanges, proximal and distal, and two joints, the MCP and the interphalangeal (IP). There are five metacarpals and five corresponding carpometacarpal (CMC) joints, which are numbered I to V from radial to ulnar. The first CMC joint is also known as the thumb basal joint (Fig. 1-2).

FIGURE 1-2

There are eight carpal bones arranged in roughly two rows. From radial to ulnar, the proximal row has the scaphoid, lunate, triquetrum, and pisiform, and the distal row has the trapezium, trapezoid, capitate, and hamate (Fig. 1-3). The bones of the distal row form the CMC joint with the base of the metacarpals and the midcarpal joint with the carpal bones of the proximal row. The proximal row articulates with the radius and the ulna. The palpable bony landmarks of the hand and wrist and their relation to the surrounding structures are depicted in Figure 1-4. The correct terminology to use when describing motion at the different joints of the hand is illustrated in Figure 1-5.

FIGURE 1-3

FIGURE 1-4

FIGURE 1-5

Examination/Imaging

Position

The patient is examined in the sitting position with elbows exposed and resting on a table in front. The examiner sits opposite the patient across the table (Fig. 1-6).

FIGURE 1-6

Procedure

We conduct our examination in stages (Table 1-1). In the first stage, we do a primary survey and focus on the hand as a whole, examining both hands. This stage begins by listening to the patient’s complaints and obtaining relevant history. This is followed by the basic examination strategy of look (inspection), feel (palpation), and move (range of motion).

The second stage is a more focused examination of one or more specific systems limited to the involved hand. The system to be examined is derived based on the primary survey. At the completion of the secondary survey, we should have a preliminary diagnosis or a differential diagnosis. If a diagnosis is not apparent, one should not make up a nebulous diagnosis such as tendinitis or arthritis. These made-up diagnoses may satisfy the patient’s need to have a reason for the discomfort but may label a patient erroneously when in fact there is no definite physiologic reason for the patient’s complaint. It is suitable to note that the patient has hand pain or wrist pain and occasionally to tell the patient that you do not know what is wrong when it is indeed truthful. We can share with the patient that we do not understand or know everything and are not able to cure every ailment.

Appropriate investigations are then ordered. The history and findings of the primary and secondary surveys are correlated with the investigations. If they do not match, a focused tertiary survey should be carried out to validate the investigation. A final diagnosis is then made and necessary treatment instituted.

Table 1-1 Systematic Examination of the Hand and Wrist

Primary Survey

The aim of the primary survey is to perform a rapid assessment of both hands to determine whether all is well.

Look

The following three regions are inspected in turn:

Palmar aspect of hand and volar forearm (Fig. 1-7)

• Fingers extended

♦ Swelling, erythema, bruising, color changes, or scars

♦ Deformity, abnormal finger posture, or amputation

♦ Wasting (thenar, hypothenar, or forearm)

• Fingers flexed

♦ Active range of joint motion

♦ Triggering

♦ Abnormal finger posture

♦ Scar adhesions during movement

Dorsal aspect of hand and forearm (Fig. 1-8)

• Hand

♦ Swelling, erythema, bruising, color changes, or scars

♦ Nail changes

♦ Wasting (first web space and intermetacarpal space)

• Dorsal aspect of forearm and elbow

♦ Swelling, erythema, bruising, color changes, or scars

♦ Wasting

• Active range of wrist motion (flexion, extension, radial and ulnar deviation, and pronosupination)

FIGURE 1-7

FIGURE 1-8

Feel

Vascularity

• Do all digits feel warm?

• Can you feel a radial pulse (Fig. 1-9)?

• Check capillary refill

Sensation (Fig. 1-10)

• Lateral aspect of midarm (C5 dermatome)

• Dorsum proximal phalanx of thumb (radial nerve, C6 dermatome)

• Tip of long finger (median nerve, C7 dermatome)

• Tip of small finger (ulnar nerve, C8 dermatome)

• Medial aspect of elbow (T1 dermatome)

Motor function (Fig. 1-11)

• Palmar abduction of thumb—abductor pollicis brevis (APB) (median nerve)

• Crossing long finger over index finger—interossei (ulnar nerve)

• Raising thumb off table—extensor pollicis longus (EPL) (radial nerve)

Autonomic function

• Skin dry?

Tenderness

• Localization of specific points of tenderness

FIGURE 1-9

FIGURE 1-10

FIGURE 1-11

Move

Assess passive range of motion

• Thumb IP and MCP joints

• Finger IP and MCP joints

• Wrist (flexion, extension, radial and ulnar deviation, and pronosupination)

♦ The normal range of motion at the different joints of the hand and wrist has been summarized in Tables 1-2 and 1-3, respectively. Extension should be measured with the goniometer placed palmar, whereas flexion is measured with the goniometer placed dorsally (Fig. 1-12). Radial and ulnar deviation of the wrist is measured with the goniometer placed along the long finger and dorsal aspect of the distal radius (Fig. 1-13). Pronation and supination should be measured with the elbow in 90 degrees flexion and the arms firmly pressed against the outer ribs (Fig. 1-14).

• At the completion of the primary survey, if something appears abnormal, one should proceed to a secondary survey. The primary survey should be able to guide us toward the anatomic system that is problematic. For example, a patient presents with history of numbness of the left thumb and index finger, and the primary survey finds diminished sensation of the left long finger tip and weakness in palmar abduction of the left thumb. The secondary survey should therefore focus on examination of the left median nerve.

Table 1-2 Normal Range of Digital Motion

Table 1-3 Normal Range of Wrist Motion

FIGURE 1-12

FIGURE 1-13

FIGURE 1-14

For an expanded version of this chapter, please see www.expertconsult.com.

Secondary Survey

The aim of the secondary survey is to do a focused examination of the anatomic system suspected by primary survey to reach a diagnosis or a differential diagnosis. We have divided the anatomic systems of the hand and wrist into four groups: (1) muscle and tendon, (2) nerve, (3) vascular, and (4) bone and joint. The following sections discuss the examination of common pathologic conditions of the hand involving these four systems and describe the various signs and provocative tests that are helpful in diagnosis. One should remember to test both hands and compare patient responses between the two sides.

Assessment of Tendon and Muscle Function

Tendinopathy: This includes a wide group of painful conditions affecting the tendons of the wrist and hand. They can be broadly classified into tenosynovitis (inflammation of the synovial lining of the tendon sheath), tendovaginitis (inflammation of the retinacular lining of the tendon sheath), tendinitis (inflammation of the tendon), tendinosis (degeneration of the tendon), and tendon subluxation.

• Tenosynovitis: This can result from infections (suppurative flexor tenosynovitis, tuberculosis, or atypical mycobacterial, gonococcal, or fungal infection) or chronic diseases (rheumatoid arthritis, gout, pseudogout, amyloidosis, or sarcoidosis). Kanavel described four cardinal signs of acute suppurative flexor tenosynovitis: a semi-flexed position of the finger, symmetrical enlargement of the whole digit (fusiform swelling), tenderness limited to the course of the flexor tendon sheath, and excruciating pain along the flexor sheath on passively extending the finger (Fig. 1-15). The chronic presentation of tenosynovitis can be identified by three findings: swelling of the palmar aspect of the digit, discrepancy between active and passive range of motion, and palpable crepitus along the course of the flexor tendon on active and passive flexion of the digit. Figure 1-16 shows a patient with rheumatoid chronic tenosynovitis. On inspection, it appears similar to acute suppurative tenosynovitis, but there is no pain on passive extension.

FIGURE 1-15

FIGURE 1-16

• Tendovaginitis: This is caused by narrowing of the retinacular sheath of the tendon. Vaginitis is a preferred term because the inflammation is not in the tendon but in the tendon sheath. The two common presentations are trigger digits and de Quervain disease. Rarely, patients present with tendovaginitis involving the EPL tendon in the third dorsal wrist compartment at Lister tubercle and the extensor indicis proprius (EIP) and extensor digiti minimi (EDM) tendons in the fourth and fifth dorsal wrist compartments.

♦ Trigger digits: The grade of triggering should be recorded for follow-up purposes (Table 1-4). One should look for tenderness over the A1 pulley and a palpable nodule. In long-standing triggers, a flexion contracture of the PIP joint may be present, and the degree of contracture should be noted.

Table 1-4 Grading of Trigger Digits

Grade I	Pretriggering	History of triggering, but not demonstrable on examination
Grade II	Active	Demonstrable triggering, but patient can actively overcome the trigger
Grade III	Passive	Demonstrable trigger, but patient cannot actively overcome trigger
IIIA	Extension	Locked in flexion and needs passive extension to overcome trigger
IIIB	Flexion	Locked in extension and needs passive flexion to overcome trigger
Grade IV	Contracture	Demonstrable trigger with flexion contracture of proximal interphalangeal joint

♦ de Quervain disease: The patient has tenderness over the radial styloid and may have triggering of the thumb extensor tendons. The following tests can be done to confirm the presence of de Quervain disease.

• Hitchhiker’s sign: The patient complains of pain localized to the first dorsal compartment when asked to extend and abduct the thumb, as is done when requesting a ride (Fig. 1-17).

FIGURE 1-17

• Finkelstein test: This is done by grasping the patient’s thumb and ulnar-deviating the wrist (Fig. 1-18). This usually results in acute pain over the radial styloid.

FIGURE 1-18

• Eichoff test: In the test described by Eichhoff (often misunderstood to be the Finkelstein test), the thumb is placed within the hand and held tightly by the other fingers. A positive test is when the wrist is painful during ulnar deviation (Fig. 1-19).

FIGURE 1-19

• Tendinitis: The common presentations of tendinitis are as follow:

♦ Intersection syndrome: The patient has tenderness at a point 4 cm proximal to Lister tubercle. This point represents the crossing over of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscle bellies over the second compartment (extensor carpi radialis longus [ECRL] and extensor carpi radialis brevis [ECRB]) (Fig. 1-20). The patient may also complain of pain at this point during the Finkelstein test or resisted wrist extension.

FIGURE 1-20

♦ Extensor carpi ulnaris (ECU) tendinitis: The patient has tenderness and crepitus along the ECU sheath and complains of pain on active resisted wrist extension and ulnar deviation. The following test has been described to differentiate between intra-articular and extra-articular pathology:

• ECU synergy test: The patient rests the arm on the examining table with the elbow flexed at 90 degrees and the forearm in full supination. The wrist is held in neutral position with the fingers in full extension. Facing the patient, the examiner grasps the patient’s thumb and long finger with one hand and palpates the ECU tendon with the other hand. The patient then radially abducts the thumb against resistance (Fig. 1-21). The presence of both flexor carpi ulnaris (FCU) and ECU muscle contraction is confirmed by direct palpation as the tendon bowstrings under the fingertips. Re-creation of pain along the dorsal ulnar aspect of the wrist is considered to be a positive test for ECU tendinitis.

FIGURE 1-21

♦ Flexor carpi radialis (FCR) tendinitis: The patient has tenderness at the palmar wrist crease over the FCR tendon near the scaphoid tubercle and complains of increased pain with resisted wrist flexion and radial deviation.

♦ FCU tendinosis: The inflammation of the FCU is referred to as tendinosis because unlike the other tendons that cross the wrist, the FCU does not have a tendon sheath. The patient has tenderness of the FCU tendon about 3 cm proximal to its insertion on the pisiform as well as pain localized to the FCU tendon with resisted flexion and ulnar deviation of the wrist (Fig. 1-22).

FIGURE 1-22

♦ ECU subluxation: This may be isolated or exist with ECU tendinitis. This can be confirmed by palpating the ECU tendon while the patient actively rotates the extended wrist from full supination to pronation. The tendon may subluxate, occasionally with an audible snap, as the supinated wrist is brought from extension into ulnar deviation and flexion.

Tendon injury: A tendon injury can result from an open wound or rupture after sustaining sudden force or from chronic attrition. The zones of acute flexor and extensor tendon injuries have been depicted in Figure 1-23. The normal finger cascade is lost with tendon injury. Figure 1-24 shows the attitude of the hand with a zone 1 flexor digitorum profundus (FDP) injury, and Figure 1-25 shows the attitude of the hand in a patient with attritional rupture of the extensor tendons to the ring and small fingers. The presence of tendon injury is confirmed by asking the patient to actively flex or extend the digits. A partial tendon laceration should be suspected in patients in whom active motion is associated with pain or triggering. In patients who cannot cooperate (e.g., children, comatose or intoxicated patients), one can look for passive movement of the fingers resulting from the wrist tenodesis effect (Fig. 1-26) or elicited by squeezing the forearm muscles (Fig.1-27). The same maneuvers can be used when trying to differentiate between tendon injury and an inability to move as a result of nerve palsy.