(English captions by Jade Cheng from the University of Michigan)
In performing the musculoskeletal exam of the wrist and hand, it is prudent to develop
a systematic approach.
The following is a suggested order of exam that incorporates the common techniques for
diagnosing musculoskeletal wrist and hand injuries.
The wrist and hand exam begins with inspection.
With the arm supinated, assess for asymmetry, thenar and hypothenar muscular atrophy, or
skin changes.
Observe for evidence of finger malrotation, which can be seen with displacement carpal
fractures.
With the hand pronated, assess for asymmetry, muscular atrophy, or skin changes.
Next evaluate active range of motion.
If pain or limitation exists, repeat the range of motion passively.
Check for wrist flexion; extension; radial deviation; ulnar deviation; thumb extension;
thumb flexion; thumb abduction and adduction; thumb opposition; digit flexion and extension
at the MCP, the PIP, and DIP joints; and digit abduction and adduction.
Next check resisted strength: wrist flexion; resisted wrist extension; resisted radial
deviation and ulnar deviation; resisted thumb extension, thumb flexion, thumb abduction,
and adduction; resisted thumb opposition; and resisted finger flexion at the MCP, extension
at the MCP, flexion at the PIP, extension at the PIP, flexion at the DIP, extension
at the DIP; digit abduction and resisted adduction.
Next palpate landmarks: the thenar eminence, the scaphoid tubercle, the hypothenar eminence,
the pisiform, and the hamate.
Palpate the radial styloid; Lister's tubercle; the anatomic snuff box; the scapholunate junction,
just proximal to the third metacarpal base; the ulna styloid; the triangular fibrocartilage
complex; along the metacarpals; and the fingers.
Specific testing of the wrist and hand to evaluate for musculoskeletal injuries may
include, but is not limited to, the following tests.
There are several tests commonly performed to evaluate for carpal tunnel syndrome.
The carpal compression test evaluates for carpal tunnel syndrome.
Provide direct compression over the carpal tunnel on the lower side of the wrist for
up to thirty seconds.
Reproduction of pain, numbness, or tingling is a positive test.
Perform a Tinel's by tapping over the carpal tunnel.
Reproduction of pain, numbness, or tingling is a positive test.
Phalen's test evaluates for carpal tunnel syndrome.
Fully flex wrists and adduct dorsal surfaces of hands together.
Reproduction of pain or tingling is a positive test.
The ulnar compression evaluates for ulnar tunnel syndrome.
Provide direct pressure over the ulnar tunnel or Guyon's canal deep to the hypothenar
eminence for up to thirty seconds.
Pain or numbness is a positive test.
Next, perform a Tinel's by tapping over the ulnar tunnel.
Reproduction of pain is a positive test.
Patients with compromise of the ulnar nerve will not be able to cross the second and third
fingers, or hold a piece of paper between their first and second fingers against resistance,
known as Frommet's sign.
Patients with compromise of anterior interosseous nerve will not be able to perform the OK sign.
An abnormal test may look like this.
There are two tests commonly performed to evaluate scapholunate instability.
The Shuck test assesses for scapholunate instability.
With the wrist flexed, the examiner resists finger extension.
Pain over the dorsum of the wrist is considered a positive test.
Watson's test assesses for scapholunate instability.
The examiner places a thumb over the patient's scaphoid tubercle, applying dorsal pressure.
The wrist is then moved from ulnar to radial deviation.
A painful clunk is considered a positive test.
Finkelstein's test evaluates for De Quervain's tenosynovitis.
The patient places the thumb in the palm, wraps fingers around it, and the wrist is
passively ulnar deviated.
Reproduction of pain is a positive test.
Testing for osteoarthritis of the thumb at the trapezium metacarpal joint is done by
using the axial grind test.
The examiner grasps the thumb and places an axial force with grinding.
Reproduction of pain is a positive test.
Ulnar collateral ligament testing of the thumb is performed to evaluate for instability found
on a gamekeeper's or skier's thumb.
After stabilizing the first metacarpal, a valgus stress is applied to the thumb at the
metacarpophalangeal joint.
Laxity indicates a partial or complete ulnar collateral ligament tear.
Several tests can be performed to evaluate for finger pain.
Evaluate the injured finger for flexion.
Inability to flex the isolated finger at the metacarpophalangeal joint may indicate a partial
or complete tear of the flexor digitorum superficialis.
Isolate the distal interphalangeal joint over the edge of the table and observe for flexion
at this joint to perform the Boyes' test.
Inability to flex at the DIP may indicate a partial or complete tear of the flexor digitorum
profundus, also known as Jersey finger.
Elson's test evaluates for partial or complete tear of the extensor digitorum.
Isolate the proximal interphalangeal joint over the edge of the table and provide resistance
against extension.
Inability to extend at the PIP is a positive test.
Ulnar collateral ligament stability can be tested at zero and thirty degrees of flexion
by applying a valgus force to the finger.
Radial collateral ligament stability can also be tested at zero and thirty degrees of flexion
by applying a varus force to the finger.
Laxity indicates a partial or complete ligament tear.
In concluding the wrist exam it is important to document a neurovascular exam.
Here we check radial artery pulse and capillary refill testing.
Further neurovascular exam may be indicated by history.
Acknowledgement: The Japanese translation of this video was made as part of Shizuoka-University of Michigan Advanced Residency Training, Education and Research in Family Medicine (SMARTER FM) Project supported by Shizuoka Prefecture and funded by the Community Healthcare Revival Fund.