Clinical Examinationof the Hand and Wrist

• Campbell’s operative orthopaedics 11th edition• Text book of orthopaedics & fractures 5th edition Dr B. Aalami Harandi• Gray’s anatomy 2nd edition• Clinical anatomy Richard S. Snell

Anatomy of the wrist

Distal radioulnar jointRadiocarpal jointUlnocarpal joint8 carpal bones (proximal and distal row and attached

ligaments)

Proximal:1. Scaphoid2. Lunate3. Triquetrum4. Pisiform (smallest)

Distal:5. Trapezium6. Trapezoid7. Capitate (largest)8. hamate

Variations

Fourth carpometacarpal articulationScaphotrapeziotrapezoid articulationCapitolunate articulationHamatolunate articulation

Articulations Radiocarpal joints Triquetrum and triangular fibrocartilage Midcarpal articulations Distal row articulations with the matacarpals

1. Mobility in the thumb

2. Stability in the index and long finger metacarpals

3. Increased mobility in the ring and little finger

Triangular fibrocartilage complexUlnar collateral ligamentDorsal and volar radioulnar ligamentArticular disc(Compressed with Pronation and

Extension Compressed with Ulnar deviation)

Meniscal homologueExtensor carpi ulnaris sheatUlnolunate and ulnotriquetral ligament

Carpal Ligaments

The major ligaments of the wrist include the palmar intrinsic ligaments, the volar extrinsic and the dorsal extrinsic and intrinsic ligamentsThe extrinsic palmar ligaments provide the

majority of the wrist stabilityThe intrinsic ligaments serve as rotational

restraints, binding the proximal row into a unit of rotational stability

Radiocarpal Joint Formed by the large articular concave surface of the distal

end of the radius, the scaphoid and lunate of the proximal carpal row, and the TFCC

extensor retinaculum

The extensor retinaculum compartments, from lateral to medial, contain the tendons of:Abductor pollicis longus and extensor pollicis

brevisExtensor carpi radialis longus and brevisExtensor pollicis longusExtensor digitorum and indicisExtensor digiti minimiExtensor carpi ulnaris

The Flexor RetinaculumTransforms the carpal arch into a tunnel, through

which pass the median nerve and some of the tendons of the hand Proximally, the retinaculum attaches to the tubercle of the

scaphoid and the pisiform Distally it attaches to the hook of the hamate, and the tubercle

of the trapezium In the condition known as ‘carpal tunnel syndrome’

the median nerve is compressed in this relatively unyielding space

Carpal Tunnel

Serves as a conduit for the median nerve and nine flexor tendons The palmar radiocarpal ligament and the palmar ligament

complex form the floor of the canal The roof of the tunnel is formed by the flexor retinaculum

(transverse carpal ligament) The ulnar and radial borders are formed by carpal bones

(trapezium and hook of hamate respectively) Within the tunnel, the median nerve divides into a motor

branch and distal sensory branches

Tunnel of Guyon

A depression superficial to the flexor retinaculum, located between the hook of the hamate and the pisiform bones The palmar (volar) carpal ligament, palmaris brevis

muscle, and the palmar aponeurosis form its roof Its floor is formed by the flexor retinaculum (transverse

carpal ligament), pisohamate ligament, and pisometacarpal ligament

The tunnel serves as a passage way for the ulnar nerve and artery into the hand

PhalangesFourteen in numberEach consist of a base, shaft, and headTwo shallow depressions, which correspond to

the pulley-shaped heads of the adjacent phalanges, mark the concave proximal bases

Two distinct convex condyles produce the pulley-shaped configuration of the phalangeal heads

Metacarpophalangeal (MCP) Joints of the 2nd-5th Fingers

The 2nd-5th metacarpals articulate with the respective proximal phalanges in biaxial joints

The MCP joints allow flexion-extension and medial-lateral deviation associated with a slight degree of axial rotation

Carpometacarpal JointsArticulation between the distal borders of the

distal carpal row bones and the bases of the metacarpals

Stability of the CMC joints is provided by the palmar and dorsal carpometacarpal and intermetacarpal ligaments

First Carpometacarpal Joint

Functionally the sellar (saddle-shaped) carpometacarpal (CMC) joint is the most important joint of the thumb

Consists of the articulation between the base of the first metacarpal and the distal aspect of the trapezium

Motions that can occur at this joint include flexion/extension, adduction/abduction and opposition (which includes varying amounts of flexion, internal rotation, and palmar adduction)

Metacarpophalangeal Joint of the Thumb

A hinge joint Consists of a convex surface on the head of the metacarpal, and

a concave surface on the base of the phalanx

Interphalangeal (IP) Joints

Adjacent phalanges articulate in hinge joints that allow motion in only one plane

The congruency of the IP joint surfaces contributes greatly to finger joint stability The proximal IP joint is a hinged joint capable of flexion and extension The distal IP joint has similar structures but less stability and allows

some hyperextension.

Palmar Aponeurosis

A dense fibrous structure continuous with the palmaris longus tendon and fascia covering the thenar and hypothenar muscles

Dupuytren’s contracture is a fibrotic condition of the palmar aponeurosis that results in nodule formation or scarring of the aponeurosis, and which may ultimately cause finger flexion contractures

Extensor Hood

A complex tendon, which covers the dorsal aspect of the digits is formed from a combination of the tendons of insertion from extensor digitorum, extensor indicis, and extensor digiti minimi

Creates a ‘cable’ system that provides a mechanism for extending the MCP and IP joints, and allows the lumbrical, and possibly interosseous muscles, to assist in the flexion of the MCP joints

Synovial Sheaths

Long narrow balloons filled with synovial fluid, which wrap around a tendon so that one part of the balloon wall (visceral layer) is directly on the tendon, while the other part of the balloon wall (parietal layer) is separate

Flexor Pulleys

Annular (A) and cruciate (C) pulleys restrain the flexor tendons to the metacarpals and phalanges and contribute to fibro-osseous tunnels through which the tendons travel A1 from the MP joint and volar plate A2 from the proximal phalanx A3 from the PIP joint volar plate A4 from the middle phalanx A5 from the DIP joint volar plate

Muscles of the Hand

Short muscles of the thumb Abductor pollicis brevis (APB) Flexor pollicis brevis (FPB) Opponens pollicis (OP) Adductor pollicis (AP)

Muscles of the Hand

Short muscles of the 5th digit Abductor digiti minimi (ADM) Flexor digiti minimi (FDM) Opponens digit minimi (ODM)

Muscles of the hand

Interosseous muscles of the hand Three palmar interossei. Each functions to adduct the digit, to which it

is attached, toward the middle digit Four dorsal interossei. Each functions to abduct the index, middle and

ring fingers from the mid-line of the hand

Muscles of the hand

Lumbricales Function to perform the motion of IP joint extension with the MCP joint

held in extension Can assist in MCP flexion

Anatomic Snuff Box

A depression on the dorsal surface of the hand at the base of the thumb, just distal to the radius

Formed by the tendons of the APL and EPB, while the ulnar border is formed by the tendon of the EPL

Along the floor of the snuffbox is the deep branch of the radial artery and the tendinous insertion of the ECRL. Underneath these structures, the scaphoid and trapezium bones are found

Neurology

The three peripheral nerves that supply the skin and muscles of the wrist and hand include the median, ulnar, and radial nerve

Vasculature of the wrist and hand

The brachial artery bifurcates at the elbow into radial and ulnar branches, which are the main arterial branches to the hand

Vascular arches of the hand Dorsal arches Palmar arches

Biomechanics The wrist contains several segments whose combined

movements create a total range of motion that is greater than the sum of its individual parts

Pronation

Approximately 90° of forearm pronation is available During pronation, the concave ulnar notch of the radius glides around

the peripheral surface of the relatively fixed convex ulnar head Pronation is limited by the bony impaction between the radius and the

ulna

Supination

Approximately 85-90° of forearm supination is available Supination is limited by the interosseous membrane, and the bony

impaction between the ulnar notch of the radius, and the ulnar styloid process

Wrist flexion and extension

The movements of flexion and extension of the wrist are shared among the radiocarpal articulation, and the intercarpal articulation, in varying proportions

Wrist flexion and extension

During wrist flexion, most of the motion occurs in the midcarpal joint (60% or 40° versus 40% or 30° at the radiocarpal joint), and is associated with slight ulnar deviation and supination of the forearm

During wrist extension, most of the motion occurs at the radiocarpal joint (66.5% or 40° versus 33.5% or 20° at the midcarpal joint), and is associated with slight radial deviation and pronation of the forearm

Radial Deviation

Radial deviation occurs primarily between the proximal and distal rows of the carpal bones

The motion of radial deviation is limited by impact of the scaphoid onto the radial styloid, and ulnar collateral ligament

Ulnar deviation

Ulnar deviation occurs primarily at the radiocarpal joint Ulnar deviation is limited by the radial collateral ligament

The handThe hand accounts for about 90% of upper limb functionThe thumb is involved in 40-50% of hand functionThe index finger is involved in about 20% of hand

functionThe middle finger, which accounts for about 20%

of all hand function, is the strongest finger, and is important for both precision and power functions

Thumb motions

Within the first CMC joint, the longitudinal diameter of the articular surface of the trapezium is generally concave from a palmar to dorsal direction

The transverse diameter is generally convex along a medial to lateral direction

The proximal articular surface of the first metacarpal is reciprocally shaped to that of the trapezium

Thumb flexion and extension

Thumb flexion and extension occur around an anterior-posterior axis in the frontal plane that is perpendicular to the sagittal plane of finger flexion and extension

In this plane, the metacarpal surface is concave, and the trapezium surface is convex

Thumb abduction and adduction

Thumb abduction and adduction occur around a medial-lateral axis in the sagittal plane, that is perpendicular to the frontal plane of finger abduction and adduction

During thumb abduction and adduction, the convex metacarpal surface moves on the concave trapezium

A number of grips have been recognized:

Fist gripCylindrical gripBall gripHook gripRing gripPincer gripPliers grip

history

What is the cause of pain?Mechanism of injury? Previous history?Location, duration and intensity of pain?Creptitus, numbness, distortion in temperature?Sounds or sensations?Technique changes?Weakness or fatigue?What provides relief?

Observation

The clinician inspects for lacerations, surgical scars, masses, localized swelling, or erythema

Scars should be examined for degree of adherence, degree of maturation, hypertrophy (excess collagen within boundary of wound), and keloid (excess collagen that no longer conforms to wound boundaries)

The location and type of edema should be noted

Examination AROM, then PROM with over pressure

The gross motions of wrist, hand, finger and thumb flexion, extension, and radial and ulnar deviation are tested, first actively and then passively

Any loss of motion compared with the contralateral, asymptomatic wrist and hand should be noted

Palpation

Palpation of the muscles, tendon, insertions, ligaments, capsules, bones of the wrist and hand should occur as indicated, and be compared with the uninvolved side

Pain provocation tests These tests are used to determine the cause of a painful or

dysfunctional motion by systematically testing each of the articulations to see whether the maneuvers reproduce the patient’s symptoms

Strength testing

Isometric tests are carried out in the extreme range, and if positive, in the neutral range

These isometric tests must include the interossei and lumbricales

The straight plane motions of wrist flexion, extension, ulnar and radial deviation are tested initially

Pain with any of these tests requires a more thorough examination of the individual muscles

Examination Functional Assessment

The functional range of motion for the hand is the range in which the hand can perform most of its grip and other functional activities

A number of assessment tools are available

Examination Passive Physiological Mobility Testing

In each of the tests, the clinician notes the quantity of motion as well as the joint reaction (end feel).

The tests are always repeated on, and compared to, the same joint in the opposite extremity

Passive Accessory Mobility Tests

In each of the tests, the clinician notes the quantity of accessory joint motion as well as the joint reaction

The tests are always repeated on, and compared to, the same joint in the opposite extremity

Ligament Stability

A number of tests are available to evaluate the ligamentous stability of the forearm, wrist, hand and finger joints

Neurovascular Status

Allen Test Tinel’s test for Carpal Tunnel Syndrome

Examination Sensibility Testing

The assessment of sensibility of the hand is an important component of every hand examination because sensation is essential for precision movements and object manipulation

Two types of sensibility are assessed Protective Functional

ExaminationSpecial tests

Carpal Shake test Sit to Stand test Ulnar Impaction test Finkelstein’s test Flexor digitorum superficialis (FDS) test Flexor digitorum profundus test Extensor Hood rupture test Froment’s sign Murphy’s sign

ExaminationDiagnostic testing

Diagnostic testing of the forearm, wrist and hand is limited to plain radiographs for most patients

Bony tenderness with a history of trauma or a suspicion of bone or joint disruption indicates a need for radiographs

Standard projections for the wrist are the posteroanterior, lateral, and oblique

For the patient with a suspicion of a scaphoid injury, a scaphoid view should be added

Radiographic Anatomy Wrist AP

Adult Wrist - Lateral View

CT scan:

CT

Radius ulna

scaphoid

Lunate

triquetrum

hamate

 Capitate

Trapezoid Trapezium

surface anatomy

MRI

ROM

Distal Radioulnar joint Supination and Pronation – 80-90o

Ulna moves posteriorly and laterally with pronation

Radiocarpal joint (and Ulnocarpal joint) Flexion (80-90o) and Extension (75-85o) Radial (20o) and Ulnar (35o) Deviation

Intercarpal joints Gliding

palpationBony and Soft Tissue Palpation Are they where they should be? Do they feel like they should feel?

Circulatory and Neurological Evaluation Hands should be felt for temperature

Cold hands indicate decreased circulation Take pulse – radial artery Pinching fingernails can also help detect circulatory problems

(capillary refill) Hand’s neurological functioning should also be tested

(sensation and motor functioning)