++
The physical examination should begin with a general observation of the patient's posture—especially the cervical spine, the thoracic spine, and the position of the hand in relation to the body. For example, is the arm held against the chest in a protective manner, does the arm swing during the gait pattern, or does it just hang loosely? The patient's hands can be highly informative (
Table 18-4). Although very subtle, the DH tends to be larger than the nondominant hand. The posture and alignment of the involved wrist and hand are examined. Wrist angulation into ulnar deviation increases shearing in the first posterior (dorsal) compartment. This angulation can predispose the patient to de Quervain syndrome (see
“Intervention Strategies”).
79A prominence of the distal ulna may indicate DRUJ instability.
80The posture of the hand should be analyzed. The clinician should observe how the patient appears to relate to the involved hand and if or how the patient attempts to use the hand.
11The contour of the anterior (palmar) surface, including the arches, should be examined. If a finger is involved, its attitude should be observed. Digital deformities are the hallmark of RA.
81
++
++
A visual inspection of the involved wrist and hand is made and is compared with the uninvolved side. The clinician inspects for lacerations, surgical scars, masses, swelling, or erythema.
++
- Scars should be examined for degree of adherence, degree of maturation, hypertrophy (excess collagen within the boundary of the wound), and keloid (excess collagen that no longer conforms to wound boundaries).
- The location and type of edema should be noted. Edema, the accumulation of fluid in the intercellular spaces, is a common consequence of surgery or injury to the hand. A determination is made as to whether the swelling is generalized or localized, hard or soft. Anterior effusion over the flexor tendons at the wrist may indicate rheumatoid tenovaginitis. Swelling that persists more than a few days following trauma probably suggests a carpal fracture. Localized swelling accompanied by redness and tenderness may indicate an infection. Measuring edema is an important part of the physical examination of individuals with conditions affecting the wrist and hand. Volumetry, a clinical application of Archimedes principle of water displacement as a measure of volume, is considered the gold standard for measuring hand size.
82This method involves lowering the limb into a water-filled Plexiglass or metal tank (the volumeter) and measuring the amount of water displaced.
83The reliability and validity of volumetric measurements is well established.
82However, this method is time consuming and requires specialized equipment. An alternative method of measuring is the figure-of-eight method. Compared to volumetric method, the figure-of-eight method is more practical for clinical use as the procedure takes less time to perform and requires equipment that is less expensive and is readily available in most clinical settings.
82The correct application of the tape is described in
Table 18-5. Leard and colleagues
82reported the figure-of-eight method to be a reliable and valid measure of hand size in individuals with conditions affecting the hand.
++
++
Clinical
Pearl
++
The normal physiologic angles for relaxed hand posture are 14–15 degrees of ulnar deviation for the index finger, 13 degrees for the middle finger, 4 degrees for the ring finger, and 7–8 degrees for the little finger.
++
The swan-neck deformity is one of the most frequently encountered deformities of the fingers (see
“Intervention Strategies”).
81When it occurs at the thumb it is referred to as a zigzag deformity. Any other finger deformities such as mallet finger and boutonniere (see
“Rheumatoid Arthritis”) are noted (
Table 18-6). Other hand deformities include the following:
++
- Ulnar drift.The classic deformity of ulnar shift and ulnar deviation is associated with RA (although it can occur in other conditions) and the MCP joints. The deformity occurs due to the cumulative effects of various factors. Initially, the MCP joint capsule and ligamentous structures are stretched by the proliferation of the synovium, which loosens the collateral ligaments and decreases joint stability (see
“Rheumatoid Arthritis”).
- Extensor plus.This deformity results from either shortening of the extensor communis tendon or adherence of the tendon to the first part of the proximal phalanx at the extensor hood. It results in the inability to flex the PIP and MCP joints simultaneously, although each joint can be flexed normally individually.
- Myelopathy hand.This deformity, which is characterized by a loss of power in abduction and extension of the ulnar fingers, is caused by cervical spinal cord pathology in conjunction with cervical spondylosis.
86Confirmation of this finding is made when lower motor neuron findings are seen at the level of the lesion while upper motor neuron findings are seen below the level of the lesion.
++
++
The nails should be inspected to see if they are healthy and pink (
Table 18-7). Local trauma to the nails seldom involves more than one or two digits. The nails should be checked for hangnail infection or whether they appear ridged, which could indicate a RA dysfunction. Clubbed nails are an indication of hypertrophy of underlying structures. The presence of a paronychia or a pale paronychia should prompt the clinician to probe the axilla and neck lymph nodes for tenderness and swelling. Beau lines are transverse furrows that begin at the lunula and progress distally as the nail grows. They result from a temporary arrest of growth of the nail matrix occasioned by trauma or systemic stress.
87With the knowledge that nails grow about 0.1 mm/day, by measuring the distance between the Beau lines and the cuticle, one may be able to approximately determine the date of the stress. For example, if the distance is 5 mm, the stress event occurred approximately 50 days before. Spoon nails (koilonychias) may occur in a form of iron deficiency anemia (Plummer–Vinson syndrome), coronary disease, and with the use of strong detergents.
87Clubbing of the nails, characterized by a bulbous enlargement of the distal portion of the digits, may occur in association with cardiovascular disease, subacute endocarditis, advanced cor pulmonale, and pulmonary disease.
87
++
++
Finger color should be observed. Fingers that are white in appearance might indicate Raynaud disease. Blotchy or red fingers might indicate liver disease. Blue fingers may indicate a circulatory problem.
++
Intrinsic muscle fibrosis is characterized by stiffness at the IP joints. On flexion of the MCP joint, extension of the fingers becomes tight and flexion is restricted. On extension of the MCP joint, flexion of the IP joints is possible.
++
- Adhesions proximal to the MCP joint allow lumbrical action (i.e., MCP flexion and PIP and DIP joint extension).
- Adhesions distal to the MCP joints result in the ability to extend the MCP and flex the PIP and DIP joints, but there is no extension possible in the fingers.
++
Palpation of the wrist and hand is an integral component of the physical examination. Palpation may be performed separately or with the range-of-motion tests. Fortunately, most of the structures are superficial (
Fig. 18-25), so a sound knowledge of surface anatomy is essential. The findings from palpation can often be confirmed using a specific special test (see
“Special Tests”). Palpation of the following muscles, tendon, insertions, ligaments, capsules, and bones should occur as indicated and be compared with the uninvolved side for tenderness and/or swelling.
++
++
The trapezium is located immediately proximal to the base of the first metacarpal bone, just distal to the scaphoid. The tubercle of the trapezium lies anteriorly at the base of the thenar eminence. It can be made more prominent by opposing the thumb to the little finger and ulnarly deviating the wrist. Tenderness over this carpal may indicate scaphotrapezial arthritis secondary to scaphoid instability.
13
++
To examine the thumb CMC joint, the clinician palpates carefully along the shaft of the thumb metacarpal down to its proximal flare. Just proximal to this flare is a small depression where the CMC joint is located. By applying direct radial and ulnar stresses to the joint, the clinician can determine the overall stability of the joint as compared to the other thumb. Tenderness here is usually indicative of degenerative arthritis.
+++
EPB, APL, and FCR Tendons
++
The EPB and APL tendons make up the first extensor compartment on the dorsum of the wrist and together form the radial border of the anatomic snuffbox. The APL is the first prominent tendon medially. Prominence of these tendons can be enhanced by extending and radially abducting the thumb. Tenderness over these tendons may indicate de Quervain tenosynovitis. Just medial to the APL is the radial artery with the FCR tendon, which inserts on the second metacarpal, situated medially.
++
The flexor retinaculum, which can be palpated just medial to the FCR, transforms the carpal arch into the carpal tunnel. It is attached medially to the pisiform and hook of the hamate and laterally to the tubercle of the scaphoid and tubercle of the trapezium. Its proximal edge is at the distal crease of the wrist. The retinaculum can be the location for a retinacular cyst which, because of its firmness, is frequently mistaken for a bony spur.
++
The hook of the hamate is palpated just distal and radial (in the direction of the thumb web space) to the pisiform on the anterior (palmar) aspect. Locating the hamate can be made easier if the clinician places the middle of the distal phalanx of the thumb on the pisiform, with the thumb pointing between the web space between the index and long finger. The clinician flexes the IP joint of the thumb and presses into the hypothenar eminence to feel the firm hook. The hook of the hamate is concave laterally, and the ulnar nerve's superficial division, which is just lateral and proximal to the hook, can be rolled on it. Tenderness over this carpal is common, and so the clinician should compare findings with the other side. Severe tenderness could indicate a fracture of the hamate, especially if associated with a FOOSH injury or a missed hit swing of a racket or bat.
88The FCU tendon surrounds the hamate as it inserts on the pisiform.
++
The pisiform is located on the flexor aspect of the palm, on top of the triquetrum, at the distal crease. Tenderness of this structure may indicate pisotriquetral arthritis or inflammation of the FCU tendon.
4The pisiform may be fractured from a direct fall or blow to the hypothenar aspect of the hand.
+++
Triangular Fibrocartilage Complex
++
The TFCC is located distal to the ulnar styloid and proximal to the pisiform. Tenderness over this structure indicates an injury to the TFCC.
4
+++
Ulnar Head and Styloid Process
++
The ulnar head forms a rounded prominence on the ulnar side of the wrist, which is easily palpated on the posterior aspect of the hand with the forearm in pronation.
80The ulnar styloid process is ulnar and distal to the head of the ulna. It is best located with the forearm in supination.
+++
Radial Styloid Process
++
The radial styloid process is larger and rounder than the ulnar styloid process. It is best palpated at the most proximal point of the anatomic snuffbox (see below), during radial abduction of the thumb. With simultaneous radial deviation of the wrist, this prominence becomes visible. Tenderness over the styloid, especially with radial deviation, may indicate contusion, fracture, or radioscaphoid arthritis.
89
++
This is a small bony prominence on the posterior (dorsal) and distal end of radius. It is found by sliding a finger proximally from a point between the index and the middle fingers. Just distal to Lister's tubercle is the joint line of the scaphoid and radius. The ECRL and ECRB tendons travel radial to Lister's tubercle and insert on the base of the second and third metacarpals. The extensor digitorum communis (EDC) tendon travels ulnarly to Lister's tubercle. Radial to Lister's tubercle and proceeding further radially are the tendons of the ECRB, ECRL, EPB, and APL.
++
The scaphoid is palpated just distal to the radial styloid in the anatomic snuffbox. The neck of the scaphoid is located on the floor of the anatomic snuffbox. Palpation can be made easier by positioning the wrist in ulnar deviation. The scaphoid may be grasped and moved passively by firm pressure between an opposed index finger and thumb applied to the anterior (palmar) surface and anatomic snuffbox simultaneously. In most individuals, the scaphoid is mildly tender to palpation, but those with a scaphoid fracture, nonunion, or scaphoid instability have severe discomfort (see
“Special Tests”).
2,
90
++
The lunate is located just distal and ulnar to Lister's tubercle with the wrist flexed and is immediately proximal to, and in line with, the capitate. The mobile lunate can be felt to glide posteriorly (dorsally) with extension. It is the most commonly dislocated carpal and the scapholunate articulation is the most common area for carpal instability. Scapholunate synovitis (posterior (dorsal) wrist syndrome) or a scapholunate ligament injury presents with tenderness or fullness in this region.
2Tenderness specific to the lunate can indicate Kienböck disease or osteonecrosis of the lunate.
91,
92
++
The capitate is localized by palpating proximally over the posterior (dorsal) aspect of the third metacarpal until a small depression is felt. While palpating in this depression, as the wrist is flexed, the clinician should feel the capitate, the central bone of the carpals, move posteriorly (dorsally). Tenderness in this depression may indicate scapholunate or lunotriquetral instability, or capitolunate degenerative joint disease.
+++
Second and Third Metacarpals
++
The base of the second and third metacarpals and the CMC joints are localized by palpating proximally along the posterior (dorsal) surfaces of the index and long metacarpals to their respective bases.
80A bony prominence found at the base of the second or third metacarpal may be a carpal boss, a variation found in some individuals due to hypertrophic changes of traumatic origin.
80
++
The triquetrum is located by radially deviating the wrist while palpating just distal to the ulnar styloid. With ulnar deviation, the triquetrum articulates with the TFCC, which functions as a buffer between the styloid and the triquetrum. Tenderness and swelling in the triquetral hamate region are often present with midcarpal instability, which occurs when the anterior (palmar) triquetral–hamate–capitate ligament is ruptured or sprained.
93
++
The tunnel of Guyon is located in the space between the hamate and the pisiform.
6
++
The distal wrist crease marks the proximal edge of the carpal tunnel. The boundaries of the carpal tunnel are as follows:
++
- Radial:scaphoid tubercle and trapezium.
- Ulnar:pisiform and hamate.
- Posterior (dorsal):the carpal bones.
- Anterior (palmar):transverse carpal ligament.
- Proximal:antebrachial fascia.
- Distal:distal edge of the retinaculum at the CMC level, FCR, and scaphoid tubercle.
++
Palpation of the PIP joint offers important information. Palpation of the joint over four planes (posterior (dorsal), anterior (palmar), medial, and lateral) allows assessment of point tenderness over ligamentous origins and insertions that is highly suggestive of underlying soft-tissue disruption.
22In cases in which the joint is grossly swollen and tender, this part of the examination may provide more accurate information several days after the injury.
22
+++
Active Range of Motion (AROM), Then Passive Range or Motion with Overpressure
++
The gross motions of wrist, hand, finger, and thumb flexion, extension, and radial and ulnar deviations are tested (
Fig. 18-14), first actively and then passively (
Table 18-8). Horger
94conducted a reliability study to determine (a) the intrarater and interrater reliability of goniometric measurement of active and passive wrist motions under clinical conditions and (b) the effect of a therapist's specialization on the reliability of measurement. The results indicated that measurement of wrist motion by individual therapists is highly reliable and that intrarater reliability is higher than interrater reliability for all active and passive motions.
94Interrater reliability was generally higher among specialized therapists for reasons not immediately apparent from this study.
94With the exception of pain, identified sources of error were found to have surprisingly little effect on the reliability of measurement.
94
++
++
Any loss of motion compared with the contralateral, asymptomatic wrist and hand should be noted.
++
During measurement of motion, one must be aware that finger joint positions may affect wrist joint ranges (and vice versa) due to the constant length of the extrinsic tendons that cross multiple joints. Forearm pronation and supination can have a similar impact on joint ranges. For example,
++
- greater wrist flexion occurs with finger extension than with finger flexion because the ED tendons are not stretched maximally;
- less deviation range of motion is available when the wrist is fully extended or flexed.
++
Thus during the examination, the clinician should maintain all joints in a consistent position (usually neutral), except the one being measured. In addition, the clinician should identify wrist and finger joint position when measuring the strength of related muscles.
++
Somatic dysfunction of the wrist permits motion toward the dysfunction; motion away from the dysfunction will be restricted.
++
Fanning and folding of the hand is performed by palpating the anterior (palmar) surface of the pisiform, scaphoid, hamate, and trapezium with the index and middle fingers and the posterior (dorsal) surface of the capitate with the thumbs as the hand is alternately fanned and folded. During these motions, the clinician should note the quantity and quality of the conjunct rotations. An absence of the conjunct rotations may indicate an intercarpal dysfunction.
++
The uninvolved joint should always be examined first. This allows for a determination of the normal function, allays the patient's anxiety, and allows for a true comparison of function.
4During palpation, the clinician should be on the alert for any thickening over tendons, tenderness, or areas of fluctuation.
4During active and passive testing, the presence of crepitus must be determined. The presence of crepitus with motion may indicate a tendon sheath synovitis or vaginitis.
++
Clinical
Pearl
++
Crepitus usually accompanies a particularly acute tendonitis.
+++
Pronation and Supination
++
Pronation and supination of the wrist on the forearm will provisionally test the TFCC and the proximal and DRUJs. Full forced pronation–supination without evoking pain eliminates the DRUJ and the TFCC as potential sources of the patient's complaints.
2Normal ranges for pronation and supination are approximately 85–90 degrees with approximately 75 degrees occurring in the forearm articulations and the remaining 15 degrees the result of wrist action. The normal end feel for these motions is tissue stretch, although in cachexic patients, the end feel of pronation may be bone to bone.
++
+++
Radial and Ulnar Deviation
++
Normal radial deviation is approximately 15 degrees, while normal ulnar deviation is between 30 and 45 degrees. The normal end feel for these motions is bone to bone.
++
++
++
++
The normal range of motion of wrist flexion is 80 to 90 degrees with an end feel of tissue stretch. According to Watson,
2any loss of passive wrist flexion is a sign of underlying organic carpal pathology. To determine whether painful wrist flexion is due to a problem between the scaphoid and radius, or the scaphoid and the trapezium and trapezoid, the wrist is placed in full flexion, with the posterior (dorsal) surface of the hand resting on the treatment table. The clinician pushes on the scaphoid and second metacarpal in a posterior (dorsal) direction. An increase in pain with this maneuver may indicate a problem at the scaphoid–radius articulation.
++
++
If there is no increase in pain with this maneuver, the wrist is placed in a neutral position with regard to flexion and extension. The clinician stabilizes the trapezium and trapezoid and pushes the scaphoid posteriorly (dorsally). An increase in pain with this maneuver may indicate a problem at the trapezium/trapezoid–scaphoid articulation.
++
To determine whether the painful wrist flexion is due to a problem between the capitate and the lunate or the lunate and the radius, the wrist is placed in full flexion. The clinician pushes the lunate in an anterior (palmar) direction. An increase in pain with this maneuver may indicate a problem at the capitate–lunate articulation. If the pain is not increased with this maneuver, the wrist is placed in full flexion and the clinician pushes the lunate in a posterior (dorsal) direction. An increase in pain with this maneuver may indicate a problem at the lunate–radius articulation. A decrease in pain with this maneuver may indicate a problem at the capitate–lunate articulation.
++
++
The normal range of motion for wrist extension is 70–90 degrees with an end feel of the tissue stretch. According to Watson,
2any loss of passive wrist extension is a sign of underlying organic carpal pathology. To determine whether the pain with wrist extension is due to a problem between the scaphoid and the radius or the scaphoid and the trapezium/trapezoid, the wrist is positioned in full extension with the palm positioned on the table. The clinician pushes on the radius in an anterior (palmar) direction, thus increasing the amount of wrist extension. An increase in pain with this maneuver may indicate a problem at the scaphoid–radius articulation. If this maneuver does not increase pain, the wrist is positioned as before. The clinician now pushes on the radius in a posterior (dorsal) direction. A decrease in pain with this maneuver may indicate a problem at the scaphoid–radius articulation. An increase in pain with this maneuver may indicate a problem at the scaphoid and trapezium/trapezoid articulation.
++
This is confirmed by placing the wrist as before in full extension and pushing on the scaphoid in a posterior (dorsal) direction. A decrease in pain with this maneuver indicates a problem between the scaphoid and the radius, whereas an increase in pain with this maneuver indicates the problem is between the scaphoid and the trapezium/trapezoid.
++
++
The clinician fixes the scaphoid and pushes the trapezium/trapezoid in an anterior (palmar) direction. A decrease in pain with this maneuver may indicate a problem at the scaphoid–trapezium/trapezoid articulation. If the pain remains unchanged with this maneuver, the problem is likely to be at the scaphoid–radius articulation. To confirm this hypothesis, the scaphoid can be pushed in an anterior (palmar) direction while the wrist is maintained in the position of full extension. This should increase the pain if the hypothesis is correct.
++
To determine whether pain is due to a problem between the capitate and lunate or the lunate and radius, the wrist is positioned in full extension, with the palm of the hand on the table. The clinician pushes on the radius in an anterior (palmar) direction. An increase in pain with this maneuver indicates a problem at the capitate–lunate articulation.
++
If the pain is increased by pushing the lunate and capitate in an anterior (palmar) direction, this may indicate a problem at the lunate–radius articulation.
++
If fixing the lunate and pushing the capitate in an anterior (palmar) direction (a relative motion of the lunate posteriorly [dorsally] in relation to the capitate) increases the pain, the problem is likely at the capitate–lunate articulation.
++
The following motions are tested in varying degrees of wrist flexion and extension:
++
- CMC abduction, adduction, flexion, extension, and opposition (
Fig. 18-16). During opposition, the clinician should observe for the conjunct rotation component of the motion.
- MCP and IP flexion and extension.
++
++
++
++
++
++
++
++
It should never be assumed that lack of full active flexion or extension of the PIP is merely secondary to joint pain or fusion, because closed rupture of the middle slip of the extensor hood is easily missed until the appearance of a boutonniere deformity.
22During flexion of the fingers, the overall area of the fingers should converge to a point on the wrist corresponding to the radial pulse. This can only occur if the index finger flexes in a sagittal plane and all the others in an increasingly oblique plane. A skyline view of the knuckles is made. In full flexion, a posteriorly (dorsally) subluxed capitate may be seen as a local swelling on the back and middle of the flexed wrist.
++
++
++
++
Total active motion of the fingers is the sum of all angles formed by the MCP, PIP, and DIP joints in simultaneous maximum active flexion, minus the total extension deficit at the MCP, PIP, and DIP joints (including hyperextension at the IP joints) in maximum active extension.
++
A normal value for total AROM in the absence of a normal contralateral digit for comparison is 260 degrees, based on 85 degrees of MCP flexion, 110 degrees of PIP motion, and 65 degrees of DIP motion.
95
++
A comparison of active and passive motion indicates the efficiency of flexor and extensor excursion and/or degree of muscle strength within the available passive range of motion (PROM).
95Instances of greater passive than active motion may indicate a limited tendon glide due to adherence of the tendon to surrounding structures or relative lengthening of the tendon due to injury or surgery, weakness, or pain.
95
++
Due to the multitude of joints and multiarticular muscles found in the hand, the clinician may need to differentiate between various structures in order to determine the cause of a motion restriction (see
“Special Tests”).
95For example, adherence of the extrinsic flexors is tested by passively maintaining the fingers and thumb in full extension while passively extending the wrist. In the presence of flexor tightness, the increasing flexor tension that develops as the wrist is passively extended will pull the fingers into flexion. Adherence of the extensor tendons is simply a reverse process. The digits are passively maintained in full flexion while the wrist is passively flexed. If tension pulling the fingers into extension is detected by the clinician's hand as the wrist is brought into flexion, extrinsic extensor tightness exists.
++
Isometric tests are carried out in the extreme range, and if positive, in the neutral range. These isometric tests must include the interossei and lumbricals. The straight plane motions of wrist flexion, extension, and ulnar and radial deviation are tested initially. Pain with any of these tests requires a more thorough examination of the individual muscles. The clinician should be able to extrapolate hand placements for these tests by noting the anatomy of these muscles from the figures. The muscles controlling wrist extension (see
Chapter 17), wrist flexion (see
Chapter 17), radial deviation, and ulnar deviation are tested first.
++
During the testing of these muscles, substitution by the finger flexors should be avoided by not allowing the patient to make a fist. The clinician applies the resistive force into extension and radial deviation for the FCU, and extension and ulnar deviation for the FCR.
++
++
++
Any action of the EDC should be ruled out by having the patient make a fist while extending the wrist. The clinician applies the resistive force on the dorsum of the second and third metacarpals, with the force directed into flexion and ulnar deviation.
++
+++
Extensor Carpi Ulnaris
++
The ECU is tested by having the patient make a fist in wrist extension, while the clinician applies resistance on the ulnar dorsum of hand, with the force directed into flexion and radial deviation.
++
++
The forearm is positioned midway between pronation and supination, or in maximal supination. The MCP and IP joints are positioned in flexion. The muscles are tested with anterior (palmar) abduction of the thumb in the frontal plane for the longus and in the sagittal plane for the brevis.
++
++
++
++
++
The forearm is positioned in supination and the posterior (dorsal) aspect of the hand rests on the table. The patient is asked to touch the finger pads of the thumb and little finger together. Using one hand, the clinician stabilizes the first and fifth metacarpals and the palm of the hand. With the other hand, the clinician applies a force to the distal end of the first metacarpal in the opposite direction of opposition (retroposition).
++
++
The forearm is positioned in supination and supported by the table, and the hand is positioned so that the posterior (dorsal) aspect rests on the table. The thumb is adducted. The longus is tested by resistance applied to the distal phalanx, whereas both heads of the brevis are tested by resistance applied to the proximal phalanx.
++
++
++
This muscle is tested by having the patient hold a piece of paper between the thumb and radial aspect of the index finger's proximal phalanx while the clinician attempts to remove it. If weak or nonfunctioning, the IP joint of the thumb flexes during this maneuver due to substitution by the FDP (Froment sign).
+++
Extensor Pollicis Longus/EPB
++
Both of these muscles can be tested with the patient's hand flat on the table, palm down, and asking the patient to lift only the thumb off the table. To test each individually, resistance is applied to the posterior (dorsal) aspect of the distal phalanx for the EPL while stabilizing the proximal phalanx and metacarpal and to the posterior (dorsal) aspect of the proximal phalanx for the EPB while stabilizing the first metacarpal.
++
++
++
The four lumbricals are tested by applying resistance to the posterior (dorsal) surface of the middle and distal phalanges, while stabilizing under the proximal phalanx of the finger being tested. The anterior (palmar) and posterior (dorsal) interossei act with the lumbricals to achieve MCP flexion coupled with PIP and DIP extension.
++
+++
Anterior (Palmar) Interossei
++
The three anterior (palmar) interossei adduct the second, fourth, and fifth fingers to midline.Resistance is applied by the clinician to the radial aspect of the distal end of the proximal phalanx of the second, fourth, and fifth fingers, after first stabilizing the hand and fingers not being tested.
++
++
+++
Posterior (Dorsal) Interossei/ADM
++
The four posterior (dorsal) interossei abduct the second, third, and fourth fingers from midline. The ADM abducts the fifth finger from midline.
++
The intrinsic muscles are tested in the frontal plane to avoid substitution by the extrinsic flexors and extensors. Resistance is applied by the clinician to the ulnar aspect of the distal end of the proximal phalanx of each of the four fingers, after first stabilizing the hand and fingers not being tested.
++
+++
Flexor Digitorum Profundus
++
This muscle is tested with DIP flexion of each digit, while the MCP and PIP are stabilized in extension and wrist neutral. Due to the variability of nerve innervation for this muscle group, each of the fingers can be tested to determine whether a peripheral nerve lesion is present. The index finger is served by the anterior interosseous nerve, the middle finger by the main branch of the median nerve, and the ring and little finger by the ulnar nerve.
++
+++
Flexor Digitorum Superficialis
++
There is normally one muscle tendon unit for each finger; however, an absent flexor digitorum superficialis to the little finger is common. The clinician should only allow the finger to be tested to flex by firmly blocking all joints of the nontested fingers, with the wrist in neutral.
++
+++
ED/Extensor Indicis Proprius
++
There is only one muscle belly for this four-tendon unit. These three muscles are the sole MCP joint extensors. With the wrist in neutral, the strength is tested with the metacarpals in extension and the PIP/DIP flexed. The extensor indicis proprius can be isolated by positioning the index finger and hand in the “number one” position—the index finger in extension with other fingers clenched in a fist. The EDM muscle is tested with resistance of little finger extension with the other fingers maintained in a fist.
++
To isolate intrinsic muscle function, the patient is asked to actively extend the MCP joint and then to attempt to actively extend the PIP joint. Because the ED, EI, and EDM tendons are “anchored” at the MCP joint by active extension, only the intrinsic muscles can now extend the PIP joint.
17To test the terminal extensor tendon function, the clinician stabilizes the middle phalanx and asks the patient to extend the DIP joint.
11
++
++
++
The forearm is positioned in supination and the posterior (dorsal) aspect of the hand rests on the table. The clinician stabilizes the fifth metacarpal and the palm with one hand, and then applies resistance to the anterior (palmar) surface of the proximal phalanx of the fifth digit with the other hand.
++
+++
Opponens Digiti Minimi
++
The forearm is positioned in supination and the posterior (dorsal) aspect of the hand rests on the table. The patient is asked to touch the finger pads of the thumb and little finger together. Using one hand, the clinician stabilizes the first and fifth metacarpals and palm of the hand. With the other hand, the clinician applies a force to the distal end of the fifth metacarpal in the opposite direction of opposition (retroposition).
++
++
A loss of grip or pinch is a measurable factor used in the determination of permanent disability by compensation boards in some states.
96
++
The assessment of grip strength (
Fig. 18-26) and pinch strength (
Fig. 18-27) is used to assess function of the hand, using a dynamometer. The average values for grip strength are given in
Table 18-9. Normal grip strength, which provides statistical analysis of males versus females.
97The mean value for the nondominant hand can be calculated from the values of the DH and the ratio.
++
++
++
++
A number of protocols using a sealed hydraulic dynamometer, such as the Jamar dynamometer (
Fig. 18-26) (Asimow Engineering Co., Santa Monica, CA), have been shown to be accurate, reliable, and valid in measuring grip strength.
98,
99These dynamometers register force in pounds per square inch, or kilopound per square centimeter, and have adjustable handles to accommodate any sized hand, or any hand that may have a limitation of finger joint motion.
100
++
Studies have demonstrated that the second handle setting of the Jamar dynamometer allows for the maximum grip strength from the patient.
100,
101The widest grip uses mostly the profundus muscles. At the narrowest grip, the profundus and superficialis muscle excursion are fully used, preventing much in the way of their contribution to the overall grip strength.
96,
100
++
Unfortunately, these tests are not purely objective, as they rely on the sincerity of effort from the patient.
102Thus a number of tests have been introduced in an attempt to aid in the detection of insincerity of effort:
++
- The five-position grip strength test.96This test uses the Jamar dynamometer and uses the five handle settings to measure grip strength at the five different grip widths. In normal and motivated patients, maximum grip strength occurs at the second or third grip width. The maximum grip strength, recorded at the first or fifth width setting, is supposed to be indicative of an insincerity of effort, although the reliability of the five-position grip strength test has been questioned.
101,
103
- The rapid exchange grip test, rapid simultaneous grip strength tests.The first test was developed by Lister.
104Both of these tests use the Jamar dynamometer and compare the maximum grip strength during a five-position static grip strength test, with the maximum grip strength recorded when gripping the dynamometer repeatedly at a fast rate (80 times per minute).
105,
106In normal and motivated patients the static measure of grip strength of grip strength should be approximately 15 percent greater than the dynamic measure, while in patients demonstrating insincerity of effort, the dynamic measure is equal to or greater than the initial static measure.
106The rapid exchange and the rapid simultaneous grip strength tests are time consuming and frequently performed erroneously in the clinical setting.
102
- The rapid repeat test.The patient is seated with their arm by their side, the elbow in 90 degrees of flexion, and the forearm and wrist in neutral. The dynamometer, set at the second handle setting, is supported by the clinician and the patient alternately grips with both right and left hands on ten occasions, or until the patient has to stop due to fatigue or discomfort. This test has been found to be an unreliable discriminator of true and faked hand weakness.
102
++
It is probably wise to combine the results of different grip strength tests before making any decisions.
107
+++
Functional Assessment
++
The hand serves many important functions that allow us to interact with others and the environment. In addition to providing a wealth of sensory information, the hand functions to grasp objects.
++
Hand functions have been further categorized by adding the terms
graspand
prehension. These terms are used to describe functions of power or precision.
20,
21
++
The
functional positionof the wrist is the position in which optimal function is likely to occur.
62,
108This position involves wrist extension of between 20 and 35 degrees, ulnar deviation of 10 to 15 degrees, slight flexion of all of the finger joints, midrange thumb opposition, and slight flexion of the thumb MCP and IP joints.
62In this position, which minimizes the restraining action of the long extensor tendons, the pulps of the index finger and thumb are in contact.
++
A number of motions can be used to quickly assess hand function, including the following:
++
Opposition of the thumb and little finger.
Padto pad mobility of the thumb and other fingers. The majority of the functional activities of the hand require at least 5 cm of opening of the fingers and thumb.
109
The ability to make three different fists:
++
- a. The hook fist (placing fingertips onto MCP joints).
- b. Standard fist.
- c. Straight fist (placing fingertips on the thenar and hypothenar eminences). The ability to flex the fingers to within 1–2 cm of the distal anterior (palmar) crease is an indication of functional range of motion for many hand activities.
109
++
The
functional range of motionfor the hand is the range in which the hand can perform most of its grip and other functional activities (
Table 18-10).
++
++
The percentage losses of digital function are as follows: thumb, 40–50%; index finger, 20%; long finger, 20%; ring finger, 10%; little finger, 5%. Loss of the hand is 90% of the upper extremity and 54% of the whole person.
++
Function of the digits is related to nerve distribution. Flexion and sensation of the radial digits, important in precision grips, are controlled mainly by the median nerve, whereas flexion and sensation of the ulnar digits, important to the power grip, are controlled by the ulnar nerve. The muscles of the thumb, used in all forms of gripping, are controlled by both the median and the ulnar nerves. The release of a grip or opening of the hand is controlled by the radial nerve. A loss of the relationship between the thumb and the index finger results in an inability to perform fine motor skills that involve pulp-to-pulp pinch, as well as functions that require power.
+++
Hand Disability Index
84
++
The patient is asked to rate the following seven questions on a scale of zero to three, with three being the most difficult.
++
- Unable to perform task = 0
- Able to complete task partially = 1
- Able to complete task but with difficulty = 2
- Able to perform task normally = 3
++
Are you able to do the following:
++
Dress yourself, including tying shoelaces and doing buttons?
Cut your meat?
Lift a full cup or glass to your mouth?
Prepare your own meal?
Open car doors?
Open jars that have previously been opened?
Turn taps on and off?
++
A variety of evaluation tools have been devised for the hand, and they can be categorized into assessments of the neurovascular system, range of motion, sensibility, and function (
Table 18-11).
109
++
++
Dexterity tests include the following:
+++
Minnesota Rate of Manipulation Test
++
This test, which primarily measures gross coordination and dexterity, consists of following five functions:
++
Placing
Turning
Displacing
One-hand turning and placing
Two-hand turning and placing
++
The activities are timed and compared with the time taken by the other hand and then compared with normal values.
109,
110
+++
Jebsen–Taylor Hand-Function Test
111
++
This test, which requires the least amount of extremity coordination, measures prehension and manipulative skills and consists of following seven subtests:
++
Writing
Card turning
Picking up small objects
Simulated feeding
Stacking
Picking up large, light objects
Picking up large, heavy objects
++
The subtests are timed and compared with the time taken by the other hand. The results are also compared with normal values.
109,
110
++
This test was designed to assess finger dexterity of each hand.
112The patient is asked to use one hand to place nine 3.2-cm (1.3-inch) pegs in a 12.7 by 12.7 cm (5 by 5 in.) board and is then asked to remove them. The task is timed and compared with the time taken by the other hand. The results are compared with normal values.
109,
110
+++
Purdue Pegboard Test
113,
114
++
This test evaluates finer coordination, requiring prehension of small objects, with measurement categories divided into
++
right hand
left hand
both hands
right, left, and both hands
assembly.
++
The subtests are timed and compared with normal values based on gender and occupation.
109,
110
+++
Crawford Small Parts Dexterity Test.
115
++
This test involves the use of tweezers and a screwdriver and requires patients to control not only their hands but also small tools. This test correlates positively with vocational activities that demand fine coordination skills.
109
++
The problem with most of these tests and others is that the critical measure of function used is time, even though time is not an accurate measure of function.
++
Although not standardized, a few other simple tests can be used to assess hand dexterity. These include writing in a straight line, buttoning and unbuttoning different-sized buttons, and zipping and unzipping using a variety of zipper sizes. The following scale can be used to grade these activities:
++
- Unable to perform task = 0.
- Able to complete task partially = 1.
- Able to complete task but with difficulty = 2.
- Able to perform task normally = 3.
+++
Passive Accessory Joint Mobility Tests
++
In the following tests, 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 tests are always repeated on, and compared to, the same joint in the opposite extremity.
+++
Distal Radioulnar Joint
+++
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 (
Fig. 18-28). The distal radius is stabilized and the distal ulna is moved posteriorly (dorsally) or anteriorly (palmarly) relative to the distal radius (
Fig. 18-28). 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.
++
++
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.
++
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 (
Fig. 18-29).
++
+++
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) (
Fig. 18-30). The posterior glide tests the joint's ability to flex, whereas the anterior glide assesses the ability of the joint to extend.
++
+++
Ulnar and Radial Glide
++
The patient's hand rests on the table with the wrist supported with a towel (
Fig. 18-31). 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.
++
++
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 (
Fig. 18-32). 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.
++
++
The same technique is used to assess the proximal row of carpals.
++
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 (
Fig. 18-33). 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.
++
++
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 (
Fig. 18-34). With a pinch grip of the index finger and thumb of the other hand, the clinician palpates the metacarpal (
Fig. 18-34).
++
++
The carpal bone is stabilized and the metacarpal is distracted (
Fig. 18-35) and then glided posterior anteriorly along the plane of the CMC joint.
++
+++
First CMC (Trapeziometacarpal) Joint
++
The patient is positioned in sitting or supine.
++
The clinician applies a glide in an ulnar direction through the thenar eminence toward the radial aspect of the patient's metacarpal (
Fig. 18-36). 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.
++
The distraction technique may be used to decrease pain and to stretch the joint capsule.
++
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.
++
The clinician stabilizes the proximal bone, and then applies a long axis distraction (
Fig. 18-37).
++
+++
Posterior–Anterior Glide
++
The clinician stabilizes the proximal bone, and then glides the phalanx posteroanteriorly along the plane of the joint (
Fig. 18-37).
+++
Ulnar (Medial)–Radial (Lateral) Glide
++
The clinician stabilizes the proximal bone, and then glides the phalanx mediolaterally along the plane of the joint (
Fig. 18-37).
++
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 (
Fig. 18-38) and DIP joint (
Fig. 18-39) 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.
++
++
++
++
The special tests for the wrist and hand can be subdivided based on intent:
++
- Motion restriction
- Pain provocation
- Tendinous integrity
- Ligamentous stability
- Neurovascular status
- Sensibility testing
- Adverse neural tension.
++
- The Bunnell–Littler test is used to determine whether flexion restriction of the PIP is due to tightness of the intrinsic muscles or due to a restriction of the MCP joint capsule. The MCP joint is held by the clinician in a few degrees of extension with one hand, while the other hand attempts to flex the PIP joint. If the joint cannot flex, tightness of the intrinsics or a joint capsular contraction should be suspected.
116From this position, the clinician now slightly flexes the MCP joint, thereby relaxing the intrinsics, and attempts to flex the PIP joint (
Fig. 18-40). If the joint can now flex, the intrinsics are tight. If the joint still cannot flex, the restriction is probably due to a capsular contraction of the joint. This test is also called the intrinsic-plus test.
23
- The Haines–Zancolli test is used to determine whether restricted flexion in the DIP joints is due to a restriction of the PIP joint capsule or tightness of the oblique retinacular ligament. The test for a contracture of this ligament is the same as the Bunnell–Littler test, only at the PIP and DIP joints. The clinician positions and holds the PIP joint in a neutral position with one hand and attempts to flex the DIP joint with the other hand (
Fig. 18-41). If no flexion is possible, it can be due to either a tight retinacular ligament or capsular contraction. The PIP joint is then slightly flexed to relax the retinacular ligament. If the DIP can now flex, the restriction is due to tightness in the retinacular ligament. If the DIP cannot flex, then the restriction is due to a capsular contraction.
++
++
+++
Pain Provocation Tests
++
The grind test is used to assess the integrity of the thumb CMC joint by axially loading the thumb metacarpal into the trapezium.
9,
117The clinician grasps the thumb metacarpal using the thumb and index finger of one hand and the proximal aspect of the thumb CMC joint with the other hand (
Fig. 18-42). An axial compressive force, combined with rotation, is applied to the thumb CMC joint. Reproduction of the patient's pain and crepitus is a positive test for arthrosis and synovitis.
++
++
The Lichtman test is a provocative test for midcarpal instability.
9The patient's forearm is positioned in pronation and the hand is held relaxed and supported by the clinician. The clinician gently moves the patient's hand from radial to ulnar deviation while compressing the carpus into the radius (
Fig. 18-43). A positive test is when the midcarpal row appears to jump or snap from an anteriorly (palmarly) subluxed position to the height of the proximal row.
9
++
++
The Linscheid test is used to detect ligamentous injury and instability of the second and third CMC joints. The test is performed by supporting the metacarpal shafts and pressing distally over the metacarpal heads in anterior (palmar) (
Fig. 18-44) and posterior (dorsal) directions.
80A positive test produces pain localized to the CMC joints.
118
++
++
This test is used if intercarpal synovitis is suspected.
9The clinician grasps the patient's distal forearm (
Fig. 18-45). The patient is asked to relax and the clinician shakes the wrist (
Fig. 18-45). Pain or resistance to this test indicates a positive test.
++
+++
Wrist Flexion and Finger Extension Test
++
The patient is positioned in sitting with the elbow placed on the table. The clinician holds the patient's wrist in flexion and asks the patient to extend the fingers against manual resistance (
Fig. 18-46). A positive test for scapholunate pathology is identified by pain over the scaphoid. No diagnostic accuracy studies have been performed to determine the sensitivity and specificity of this test.
++
+++
Press (Sit to Stand) Test
++
This test is used if a tear of the TFCC is suspected.
9The patient is instructed to place both hands on the armrests of a chair and attempt to lift their body slightly off the chair (
Fig. 18-47). Pain or resistance to this test indicates a positive test. Lester and colleagues
119reported a sensitivity of 100% compared with arthroscopic surgery and a sensitivity of 79% when compared with magnetic resonance imaging (MRI) arthrogram. Specificity could not be determined based on the methodology of this test design.
++
+++
Supination Lift Test
120
++
The patient is positioned in sitting with the elbows flexed to 90 degrees and the forearms supinated. The patient is asked to place the palms flat on the underside of the heavy table or against the clinician's hands. The patient is asked to lift the table or push up against the resisting clinician's hands (
Fig. 18-48). A positive test for a TFCC tear is pain localized to the ulnar side of the wrist with difficulty applying force.
++
++
This test is used to assess the articulation between the ulnar carpus and the TFCC.
9The patient is positioned in sitting, with the elbow flexed to about 90 degrees and the wrist positioned in ulnar deviation, and the fingers positioned in a slight fist. The clinician loads the wrist by applying a compressive force through the ring and small metacarpals (
Fig. 18-49). Pain with this test indicates a possible tear of the TFCC or ulnar impaction syndrome (see
“Intervention Strategies”).
++
++
This test is used to detect stenosing tenosynovitis of the APL and EPB. The clinician grasps the patient's thumb, stabilizes the forearm with one hand, and then deviates the wrist to the ulnar side with the other hand (
Fig. 18-50). No diagnostic accuracy studies have been performed to determine the sensitivity and specificity of this test, so the results of this test must be interpreted with caution,
122as it may also be positive in Wartenberg syndrome (entrapment of the superficial radial sensory nerve),
123–
125basilar thumb arthrosis, EPB entrapment, or intersection syndrome (see
“Intervention Strategies”).
125Deviating the wrist using pressure over the index metacarpal avoids confusion with thumb conditions.
126A variation of Finkelstein test can be used to rule out an incomplete release of previous de Quervain disease.
127If the usual Finkelstein test is positive, full abduction of the APL followed by flexion of the thumb's MCP joint will isolate the action of the EPB. Pain with this test will occur if the EPB lies in a separate sheath and was not released (EPB entrapment syndrome).
127This test has been found to have a sensitivity of 81% and a specificity of 50%.
128
++
+++
Radioulnar Ballottement Test
++
The radioulnar ballottement test is used to assess DRUJ instability. The patient's elbow is flexed and the clinician uses their thumb and index finger to stabilize the radius radially and the ulnar head ulnarly (
Fig. 18-51). Stress is applied in an anterior–posterior direction. Normally there is no movement in the anterior or posterior direction in maximum supination or pronation. Pain or mobility with this test is suggestive of radioulnar instability.
++
++
The Wartenberg test is used with patients who complain of pain over the distal radial forearm associated with paresthesias over the posterior (dorsal) radial hand (Wartenberg syndrome). These patients frequently report symptom magnification with wrist movement or when tightly pinching the thumb and index digit together. The Wartenberg test involves tapping the index finger over the superficial radial nerve (similar to the Tinel test for CTS) on the posterior and radial side of the wrist (
Fig. 18-52). A positive test is indicated by local tenderness and paresthesia with this maneuver. Hyperpronation of the forearm can also cause a positive Tinel sign.
++
+++
Finger Extension Test
++
This test is used to demonstrate posterior (dorsal) wrist syndrome, a localized scapholunate synovitis.
13The clinician instructs the patient to fully flex the wrist and then actively extend the digits at both the IP and MCP joints. The clinician then applies pressure on the fingers into flexion at the MCP joints while the patient continues to actively extend (
Fig. 18-53). A positive test occurs when there is production of central posterior (dorsal) wrist pain and indicates the possibility of Kienböck disease, carpal instability, joint degeneration, or synovitis (see
“Intervention Strategies”).
9
++
+++
Scapholunate Shear Test
++
The patient is positioned in sitting with their forearm pronated. With one hand, the clinician grasps the scaphoid. With the other hand, the clinician grasps the lunate between the thumb and the index finger (
Fig. 18-54). The lunate and scaphoid are then sheared in an anterior (palmar) and then posterior (dorsal) direction.
2Laxity and reproduction of the patient's pain are positive signs for this test.
9
++
++
This test is used to test the integrity of the FDS tendon. The clinician holds the patient's fingers in extension except for the finger being tested (this isolates the FDS tendon). The patient is instructed to flex the finger at the PIP joint (
Fig. 18-55). If this is possible, the FDS tendon is intact. Since this tendon can act independently because of the position of the finger, it is the only functioning tendon at the PIP joint. The DIP joint, motored by the FDP, has no power of flexion when the other fingers are held in extension.
++
++
These tendons work only in unison. To test the FDP, the PIP joint and the MCP joints are stabilized in extension (
Fig. 18-56). The patient is asked to flex this finger at the DIP joint. If flexion occurs, the FDP is intact. If no flexion is possible, the tendon is severed or the muscle denervated.
++
+++
Integrity of the Central Slip (Extensor Hood Rupture)
129
++
The patient flexes the finger to 90 degrees at the PIP joint over the edge of the table. The patient is then asked to extend the PIP joint while the clinician palpates the middle phalanx (
Fig. 18-57). The absence of extension force at the PIP joint, and fixed extension at the distal joint, indicates complete rupture of the central slip.
22No diagnostic accuracy studies have been performed to determine the sensitivity and the specificity of the clinical test.
++
+++
Ligamentous Stability
++
A number of tests are available to evaluate the ligamentous stability of the forearm, wrist, hand, and finger joints. In the following tests, the patient is positioned in sitting, and the clinician is standing or sitting, facing the patient. The clinician must remember to perform these tests on the uninvolved side to provide a basis for comparison.
++
The piano key test evaluates the stability of the ulnomeniscotriquetral joint.
4The clinician firmly stabilizes the distal radius with one hand and grasps the head of the ulna between the thumb and the index finger of the other hand. The ulnar head is depressed in an anterior direction (as in depressing a key on a piano) (
Fig. 18-58).
9The test is positive for a TFCC tear or triquetral instability if there is excessive movement in an anterior (palmar) direction or if upon release of the ulna, the bone springs back into its high posterior (dorsal) position. There may also be discomfort reported during the test.
80LaStayo and Howell
130found this test to have a sensitivity of 66% and a specificity of 64%.
++
+++
Lunotriquetral Shear (Reagan) Test
++
This test is designed to assess the integrity of the lunotriquetral ligament.
4The clinician grasps the triquetrum between the thumb and the second finger of one hand and the lunate with the thumb and second finger of the other hand. The lunate is moved posteriorly (dorsally) with the thumb of one hand, while the triquetrum is pushed palmarly in the anteroposterior (AP) plane by the index finger of the other hand (
Fig. 18-44). Crepitation, clicks, or discomfort in this area suggests injury to the ligament.
9,
131LaStayo and Howell
130found this test to have a sensitivity of 64% and a specificity of 44% (LR+ 1.14; LR− 0.82).
+++
The Pisotriquetral Shear Test
++
The pisotriquetral shear test assesses the integrity of the pisotriquetral articulation.
9The clinician stabilizes the wrist with the fingers posterior (dorsal) to the triquetrum and the thumb over the pisiform. The pisiform is rocked back and forth in a medial and lateral direction. A positive test is manifested with pain during this maneuver. No diagnostic accuracy studies have been performed to determine the sensitivity and specificity of this test.
+++
Pivot Shift Test of the Midcarpal Joint
++
The patient is positioned in sitting with the elbow flexed to 90 degrees and the forearm supinated. The clinician uses one hand to stabilize the forearm, while using the other hand to take the patient's hand into full radial deviation (
Fig. 18-59). The patient's hand is then taken into full ulnar deviation. A positive test results if the capitate is felt to shift away from the lunate and indicates an injury to the anterior capsule and interosseous ligaments.
23No diagnostic accuracy studies have been performed to determine the sensitivity and the specificity of this test.
++
+++
Watson Test for Carpal Instability
++
The scaphoid shift maneuver examines the dynamic stability of the wrist, in particular the integrity of the scapholunate ligament.
13The patient is positioned in sitting with their elbow in approximately 90 degrees of flexion, the forearm slightly pronated, and the wrist ulnarly deviated. The clinician grasps the wrist from the radial side and stabilizes the scaphoid tubercle with the thumb and the posterior (dorsal) aspect of the scaphoid with the index finger. The clinician uses the other hand to grasp the metacarpals. Starting in ulnar deviation in slight extension, the wrist is moved into radial deviation and slight flexion. As the wrist is brought passively into radial deviation, the normal flexion of the proximal row forces the scaphoid tubercle into an anterior (palmar) direction (into the clinician's thumb). The clinician attempts to prevent the anterior (palmar) motion of the scaphoid. When the scaphoid is unstable, its proximal pole is forced to sublux posteriorly (dorsally).
9Pain at the posterior (dorsal) wrist or a clunk suggests instability.
26,
29The results are compared with the other hand. The results from the scaphoid shift test, which has been found to have a sensitivity of 69 percent and a specificity of between 64 and 68 percent,
91,
92,130,
132should be used with caution, as the test can be positive in up to one-third of uninjured individuals.
14
++
This is a slight modification to the Watson test. The patient positioning is similar to the Watson test except that the wrist is positioned in neutral to slight (0–10 degrees) radial deviation and neutral wrist flexion/extension. The clinician then quickly pushes the tubercle of the scaphoid in a posterior (dorsal) direction, noting a clunk, crepitus, or pain in comparison to the opposite wrist.
133No diagnostic accuracy studies have been performed to determine the sensitivity and the specificity of this test.
+++
Gamekeeper's or Skier's Thumb
++
The patient is positioned in sitting. The clinician stabilizes the patient's hand with one hand and takes the patient's thumb into extension with the other hand. While maintaining the thumb into extension, the clinician applies a valgus stress to the MCP joint of the thumb to stress the UCL (
Fig. 18-60). A positive test is present if the valgus movement is greater than 30–35 degrees, indicating a complete tear of the UCL and the accessory collateral ligaments. Heymen and colleagues
134reported a high sensitivity with this test (94%) and a 100% sensitivity and 46% specificity for detection of a palpable mass proximal to the MCP joint to indicate a complete tear of the UCL of the thumb.
++