WEBVTT

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(English captions by Jade Cheng from the University of Michigan)

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In performing the musculoskeletal exam of
the wrist and hand, it is prudent to develop

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a systematic approach.

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The following is a suggested order of exam
that incorporates the common techniques for

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diagnosing musculoskeletal wrist and hand
injuries.

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The wrist and hand exam begins with inspection.

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With the arm supinated, assess for asymmetry,
thenar and hypothenar muscular atrophy, or

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skin changes.

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Observe for evidence of finger malrotation,
which can be seen with displacement carpal

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fractures.

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With the hand pronated, assess for asymmetry,
muscular atrophy, or skin changes.

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Next evaluate active range of motion.

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If pain or limitation exists, repeat the range
of motion passively.

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Check for wrist flexion; extension; radial
deviation; ulnar deviation; thumb extension;

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thumb flexion; thumb abduction and adduction;
thumb opposition; digit flexion and extension

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at the MCP, the PIP, and DIP joints; and digit
abduction and adduction.

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Next check resisted strength: wrist flexion;
resisted wrist extension; resisted radial

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deviation and ulnar deviation; resisted thumb
extension, thumb flexion, thumb abduction,

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and adduction; resisted thumb opposition;
and resisted finger flexion at the MCP, extension

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at the MCP, flexion at the PIP, extension
at the PIP, flexion at the DIP, extension

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at the DIP; digit abduction and resisted adduction.

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Next palpate landmarks: the thenar eminence,
the scaphoid tubercle, the hypothenar eminence,

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the pisiform, and the hamate.

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Palpate the radial styloid; Lister's tubercle;
the anatomic snuff box; the scapholunate junction,

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just proximal to the third metacarpal base;
the ulna styloid; the triangular fibrocartilage

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complex; along the metacarpals; and the fingers.

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Specific testing of the wrist and hand to
evaluate for musculoskeletal injuries may

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include, but is not limited to, the following
tests.

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There are several tests commonly performed
to evaluate for carpal tunnel syndrome.

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The carpal compression test evaluates for
carpal tunnel syndrome.

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Provide direct compression over the carpal
tunnel on the lower side of the wrist for

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up to thirty seconds.

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Reproduction of pain, numbness, or tingling
is a positive test.

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Perform a Tinel's by tapping over the carpal
tunnel.

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Reproduction of pain, numbness, or tingling
is a positive test.

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Phalen's test evaluates for carpal tunnel
syndrome.

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Fully flex wrists and adduct dorsal surfaces
of hands together.

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Reproduction of pain or tingling is a positive
test.

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The ulnar compression evaluates for ulnar
tunnel syndrome.

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Provide direct pressure over the ulnar tunnel
or Guyon's canal deep to the hypothenar

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eminence for up to thirty seconds.

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Pain or numbness is a positive test.

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Next, perform a Tinel's by tapping over
the ulnar tunnel.

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Reproduction of pain is a positive test.

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Patients with compromise of the ulnar nerve
will not be able to cross the second and third

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fingers, or hold a piece of paper between
their first and second fingers against resistance,

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known as Frommet's sign.

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Patients with compromise of anterior interosseous
nerve will not be able to perform the OK sign.

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An abnormal test may look like this.

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There are two tests commonly performed to
evaluate scapholunate instability.

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The Shuck test assesses for scapholunate instability.

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With the wrist flexed, the examiner resists
finger extension.

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Pain over the dorsum of the wrist is considered
a positive test.

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Watson's test assesses for scapholunate
instability.

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The examiner places a thumb over the patient's
scaphoid tubercle, applying dorsal pressure.

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The wrist is then moved from ulnar to radial
deviation.

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A painful clunk is considered a positive test.

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Finkelstein's test evaluates for De Quervain's
tenosynovitis.

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The patient places the thumb in the palm,
wraps fingers around it, and the wrist is

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passively ulnar deviated.

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Reproduction of pain is a positive test.

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Testing for osteoarthritis of the thumb at
the trapezium metacarpal joint is done by

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using the axial grind test.

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The examiner grasps the thumb and places an
axial force with grinding.

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Reproduction of pain is a positive test.

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Ulnar collateral ligament testing of the thumb
is performed to evaluate for instability found

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on a gamekeeper's or skier's thumb.

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After stabilizing the first metacarpal, a
valgus stress is applied to the thumb at the

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metacarpophalangeal joint.

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Laxity indicates a partial or complete ulnar
collateral ligament tear.

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Several tests can be performed to evaluate
for finger pain.

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Evaluate the injured finger for flexion.

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Inability to flex the isolated finger at the
metacarpophalangeal joint may indicate a partial

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or complete tear of the flexor digitorum superficialis.

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Isolate the distal interphalangeal joint over the
edge of the table and observe for flexion

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at this joint to perform the Boyes' test.

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Inability to flex at the DIP may indicate
a partial or complete tear of the flexor digitorum

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profundus, also known as Jersey finger.

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Elson's test evaluates for partial or complete
tear of the extensor digitorum.

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Isolate the proximal interphalangeal joint
over the edge of the table and provide resistance

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against extension.

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Inability to extend at the PIP is a positive
test.

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Ulnar collateral ligament stability can be
tested at zero and thirty degrees of flexion

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by applying a valgus force to the finger.

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Radial collateral ligament stability can also
be tested at zero and thirty degrees of flexion

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by applying a varus force to the finger.

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Laxity indicates a partial or complete ligament
tear.

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In concluding the wrist exam it is important
to document a neurovascular exam.

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Here we check radial artery pulse and capillary
refill testing.

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Further neurovascular exam may be indicated
by history.

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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.