Musculoskeletal problems of the wrist and hand physical examination: Difference between revisions
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** Radiocarpal joint flexion and extension | ** Radiocarpal joint flexion and extension | ||
** Normal flexion 90°, extension 80° | ** Normal flexion 90°, extension 80° | ||
** Mild pain/stiffness + normal ROM- sprain or mild arthritis | ** Mild pain/stiffness + normal ROM- [[sprain]] or mild [[arthritis]] | ||
** Moderate pain/stiffness + 20% loss ROM- arthritis | ** Moderate pain/stiffness + 20% loss ROM- arthritis | ||
** Severe pain/stiffness + 50% loss ROM- acute gout, fracture (navicular/distal radius), dislocation | ** Severe pain/stiffness + 50% loss ROM- acute [[gout]], [[fracture]] (navicular/distal radius), [[dislocation]] | ||
** Refusal to move- septic joint, fracture | ** Refusal to move- septic joint, fracture | ||
** Loss of ROM in only one direction (due to pain) | ** Loss of ROM in only one direction (due to pain) | ||
*** Tendon injury or inflammation | *** Tendon injury or inflammation | ||
*** Pain with passive stretching of tendon (opposite direction) | *** Pain with passive stretching of [[tendon]] (opposite direction) | ||
* '''Grip Strength''' | * '''Grip Strength''' | ||
** Indirect measure of strength/integrity of forearm muscles | ** 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) | ** Can be measured objectively using rolled up partly inflated blood pressure (BP) cuff (patient grip measured in mmHg) | ||
** Reduced | ** Reduced grip strength | ||
*** Disuse atrophy, arthritis (hand or wrist), CTS, DeQuervain’s, osteonecrosis | *** Disuse [[atrophy]], arthritis (hand or wrist), CTS, DeQuervain’s, [[osteonecrosis]] | ||
*** May also be reduced in C8 radiculopathy, severe epicondylitis | *** May also be reduced in C8 [[radiculopathy]], severe [[epicondylitis]] | ||
=== Specific Maneuvers === | === Specific Maneuvers === | ||
* '''Palpation of the Radiocarpal Joint Line''' | * '''Palpation of the Radiocarpal Joint Line''' | ||
*** Junction of distal radius, scaphoid & lunate | *** Junction of distal radius, [[scaphoid]] & lunate | ||
*** At intersection of index finger extensor tendon & distal radius | *** At intersection of index finger extensor tendon & distal radius | ||
** Mild tenderness- simple sprain | ** Mild tenderness- simple sprain | ||
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* '''Palpation of the Radial Styloid''' | * '''Palpation of the Radial Styloid''' | ||
** Pain suggests DeQuervain’s tenosynovitis (friction-induced irritation of anatomic snuffbox tendons) | ** Pain suggests DeQuervain’s tenosynovitis (friction-induced irritation of anatomic snuffbox tendons) | ||
** Confirmatory | ** Confirmatory testing | ||
*** Pain aggravated by thumb extension or abduction against resistance | *** Pain aggravated by thumb extension or abduction against resistance | ||
**** (Abduction = movement of thumb perpendicular to palm) | **** (Abduction = movement of thumb perpendicular to palm) | ||
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** Ganglion cyst should be highly mobile and fluctuant, not adherent; ROM should be full | ** Ganglion cyst should be highly mobile and fluctuant, not adherent; ROM should be full | ||
** Aspiration of cyst yields thick, colorless fluid | ** Aspiration of cyst yields thick, colorless fluid | ||
== References == | == References == | ||
{{Reflist}} | {{Reflist}} | ||
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[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Musculoskeletal Disease]] | [[Category:Musculoskeletal Disease]] | ||
[[Category:Needs overview]] | [[Category:Needs overview]] |
Latest revision as of 22:49, 29 July 2020
Musculoskeletal problems of the wrist and hand Microchapters |
Differentiating Musculoskeletal problems of the wrist and hand from other Diseases |
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Directions to Hospitals Treating Musculoskeletal problems of the wrist and hand |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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)
- Pain aggravated by thumb extension or abduction against resistance
- 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