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Special Test

Wrist & Hand Examination

Wrist & Hand Examination is done with the patient is positioned in sitting or supine, with the arm resting comfortably. In each of the tests, the clinician notes the quantity of joint motion as well as the joint reaction.

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

See Also: Hand Anatomy

Wrist Examination

Wrist Examination follows the familiar ‘look, feel, move’ sequence followed by special tests. The hand, wrist and forearm should be exposed.

See Also: Wrist Anatomy

Wrist Inspection

Look for deformity, swellings, scars or muscle wasting. As the wrist is subcutaneous any deformity due to previous fracture or swellings should be easily visible.

Wrist Palpation

After asking the patient if there is a tender spot, start at the radial side of the wrist and move in a circle around the wrist, palpating the tender area last and with care.

Wrist Movements

Start with active followed by passive movements:

  1. Normal dorsiflexion is 75° test with palms together and lifting up the elbows
  2. Normal palmar flexion is 75°. Dorsum of hands should be in contact and drop the elbows.
  3. Normal radial deviation is 20° and ulnar deviation 35° in the neutral position.
  4. Test pronation–supination with elbows tucked in by the side. Ask the patient to hold a pen and measure the angle between vertical and pen.
  5. Normal pronation is 75° and supination is normally 80°.
See Also: Hand & Wrist Movements

Distal Radioulnar Joint DRUJ Examination

Anterior–Posterior Glide:

The patient is positioned in sitting with the forearm resting on the table. Using a pinch grip with both hands, the clinician places both thumbs on the posterior (dorsal) aspects of the ulnar and radial styloid processes. The distal radius is stabilized and the distal ulna is moved posteriorly (dorsally) or anteriorly (palmarly) relative to the distal radius.

Alternatively, the distal ulna may be stabilized and the distal radius moved. This technique is used to assess joint plane motions necessary for pronation (posterior glide) and supination (anterior glide), or in the case of joint mobilizations to increase the joint play necessary for these motions.

Mobility testing of the distal radioulnar joint
Mobility testing of the distal radioulnar joint

Radiocarpal Joint:

The patient’s hand rests on the table with the wrist supported with a towel. The radiocarpal and ulnocarpal joints are placed in the resting position.

Distraction: Using one hand, the clinician grasps the distal radius and ulna. Using the other hand, the clinician grips the proximal row of carpals. A perpendicular distraction force is applied to separate the proximal level of carpals from the distal radius and ulna

Radiocarpal distraction
Radiocarpal distraction

Posterior–anterior glide:

Using one hand to stabilize the patient’s distal forearm, the clinician grasps the patient’s hand with the other hand using the styloid processes and pisiform for landmarks. The proximal row of carpals is then moved posteriorly (dorsally) and anteriorly (palmarly).

The posterior glide tests the joint’s ability to flex, whereas the anterior glide assesses the ability of the joint to extend.

Anterior glide of the radiocarpal joint
Anterior glide of the radiocarpal joint

Ulnar and radial glide:

The patient’s hand rests on the table with the wrist supported with a towel. Using one hand to stabilize the patient’s distal forearm, the clinician grasps the patient’s hand with the other hand using the styloid processes and pisiform for landmarks. The proximal row of carpals is then moved posteriorly (dorsally) and anteriorly (palmarly).

The ulnar (medial) glide tests the joint’s ability to radially deviate, whereas the radial (lateral) glide assesses the ability of the joint to ulnarly deviate.

Ulnar glide of the radioulnar joint
Ulnar glide of the radioulnar joint

Intercarpal Joints

Distal row:

The patient’s hand rests on the table or is held forward by the clinician. The clinician grasps the patient’s hand with both hands, with the index fingers and thumbs of each hand used to pinch an individual carpal and the adjacent carpal.

One carpal is moved anteriorly relative to the other and the clinician assesses the motion of the carpal in relation to the other. For example, the clinician assesses the motion of the capitate in relation to the hamate. An anterior glide of one carpal on another is a relative posterior glide of the other. For example, an anterior glide of the capitate on the hamate is a relative posterior glide of the hamate on the capitate.

Proximal row:

The same technique is used to assess the proximal row of carpals.

Assessment of joint mobility of distal carpals
Assessment of joint mobility of distal carpals

Midcarpal Joints:

The articulation between the proximal row of carpals and the distal row of carpals can be assessed using distraction, anterior glide, posterior glide, radial glide, and ulnar glide. While assessing the distraction and anterior and posterior glides provides little information, the assessment of the radial glide can provide information about the ability of the wrist joint to ulnarly deviate, and the assessment of the ulnar glide can provide information about the ability of the wrist joint to radially deviate.

intercarpals joint examination
Assessment of joint mobility of intercarpals between
distal and proximal rows

Hand Examination

Hand examination include examine the CMC joints, First CMC (trapeziometacarpal) Joint, MCP and IP joints.

The broad topics in hand examination are deformities, neurological conditions and painful conditions. The principles of look, feel, move followed by special tests still apply.

Inspection

Expose the whole forearm and hand. Look at the dorsum and the palm and check for muscle wasting of the thenar, hypothenar and first dorsal interosseus. Ask the patient to open and close the hand quickly to assess mass movement of the hand.

Palpation

Ask for and feel the tender area if there is one. Pay particular attention to any swellings and nodules that may be present.

Movement

Ask the patient to make a fist (active mass motion) and then extend all fingers. Then examine the thumb, asking for opposition to all fingers in turn followed by adduction, abduction and flexion. The extensor pollicis longus (EPL) is then tested by asking the patient to lift the thumb off the table while the hand is held palm down on table.

The extensor digitorum communis is then tested by asking the patient to extend the fingers at the metacarpophalangeal (MCP) joints. The interossei are tested by asking the patient to abduct and adduct fingers. Remember that dorsal interossei abduct (DAB) and palmar interossei adduct (PAD).

Be sure to check the flexor digitorum superficialis (FDS) individually by holding other fingers in hyperextension, followed by the flexor digitorum profundus (FDP), which is tested by fixing the proximal interphalangeal (PIP) joint and thus isolating the distal interphalangeal (DIP) joint.

Hand Examination by joints

CMC Joints:

Using one hand, the clinician uses a pinch grip of the index finger and thumb to palpate and stabilize the carpal bone that articulates with the metacarpal bone being tested. With a pinch grip of the index finger and thumb of the other hand, the clinician palpates the metacarpal.

The carpal bone is stabilized and the metacarpal is distracted and then glided posterior anteriorly along the plane of the CMC joint.

First CMC (trapeziometacarpal) Joint:

The patient is positioned in sitting or supine.

Ulnar (medial) glide: The clinician applies a glide in an ulnar direction through the thenar eminence toward the radial aspect of the patient’s metacarpal. The ulnar glide is used to assess trapeziometacarpal joint flexion.

Radial (lateral) glide: The clinician applies a glide in a radial direction through the thenar eminence toward the ulnar aspect of the patient’s metacarpal. The radial glide is used to assess trapeziometacarpal joint extension.

Distraction: The distraction technique may be used to decrease pain and to stretch the joint capsule.

MCP/IP Joints:

Using a pinch grip of the index finger and thumb of one hand, the clinician palpates and stabilizes the metacarpal/phalanx. With a pinch grip of the index finger and thumb of the other hand, the clinician palpates the adjacent phalanx.

Distraction: The clinician stabilizes the proximal bone, and then applies a long axis distraction.

Posterior–Anterior Glide: The clinician stabilizes the proximal bone, and then glides the phalanx posteroanteriorly along the plane of the joint.

Ulnar (Medial)–Radial (Lateral) Glide: The clinician stabilizes the proximal bone, and then glides the phalanx mediolaterally along the plane of the joint

See Also: Grip Strength Test

First MCP Joint:

Using a pinch grip of the index finger and thumb of one hand, the clinician stabilizes the trapezium on the radial and ulnar surfaces. With a pinch grip of the index finger and thumb of the other hand, the clinician grips the proximal metacarpal on the radial and ulnar surfaces. A radial–ulnar glide is then performed by the mobilizing hand. A radial glide is necessary for trapeziometacarpal extension, whereas the ulnar glide is necessary for trapeziometacarpal flexion.

Distal and PIP Joints:

Using a pinch grip of the index finger and thumb of one hand, the clinician stabilizes the distal end of the more proximal phalanx. Using the other hand the clinician grips the proximal end of the more distal phalanx.

The PIP joint and DIP joint can then be distracted, or glided anteriorly or posteriorly. The anterior glide assesses the ability of the joint to move into flexion, whereas posterior glide assesses the ability of the joint to move into extension.

References

  1. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
  2. Ronald McRae – Clinical Orthopaedic Examination 6th Edition Book.
  3. Mercer’s Textbook of Orthopaedics and Trauma, Tenth edition.
  4. Reavey PL, Hammert WC. Examination of the Wrist. Plast Reconstr Surg. 2021 Feb 1;147(2):284e-294e. doi: 10.1097/PRS.0000000000007520. PMID: 33565836.
  5. Day CS, Wu WK, Smith CC. Examination of the Hand and Wrist. N Engl J Med. 2019 Mar 21;380(12):e15. doi: 10.1056/NEJMvcm1407111. PMID: 30893537.
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