Complete Musculoskeletal Exam of the Hand and Wrist

(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.