Transcript Hand and Wrist Evaluation

Hand and Wrist
Evaluation
History
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How did this injury occur (mechanism)
When did you hurt your wrist/thumb?
Where does it hurt?
Did you hear any sounds or feel a pop?
Any previous history?
Pain Levels & Types of Pain
Training Methods
What activities recreates the pain?
Did you continue activity after injury?
Observation
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Obvious Deformities
Discoloration / ecchymosis
Swelling
Attitude of hand
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Slightly flex at all joints when at rest
Bilateral Comparison of wrist/hand
Palmar surface, dorsal surface, knuckles,
finger nails
Palpation
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Boney
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Radius
Ulna
Anatomical Snuffbox
Metacarpals
Phalanges
Carpal Bones
Palpation Continued
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Soft Tissue
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Tunnels 1 - 6
Carpal Tunnel
Tunnel of Guyon
Thenar eminence
Hypothenar eminence
Palmar aponeurosis
Tunnels of the Wrist
Carpal Tunnel
Tunnel of Guyon
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Structures in the
Tunnel of Guyon
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Ulnar nerve and
Ulnar artery
The nerve and
artery runs right
between the Hook
of the Hamate and
the pisiform
Thenar Eminence
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Thenar Eminence
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Located under the thumb
Made up of 3 muscles
More developed on dominant hand
Supplied by Median Nerve
Observations
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Size
Shape
Consistancy
Atrophy or Hypertrophy
Hypothenar Eminence
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Hypohenar Eminence
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Runs from Pinkie to
Pisiform
Made up of 3 muscles
More developed on
dominant hand
Supplied by the Ulnar nerve
Observations
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Size
Shape
Consistency
Atrophy or hypertrophy
Palmar Aponeurosis
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Center of the hand
Shape of a Triangle
Finger Flexors run
through this
Unable to palpate
muscles due to thick
fibrous tissue
Conditions found in the Wrist/Hand
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Ganglion Cyst
DeQuervain’s Disease
Fractured Bone
(Scaphoid)
Carpal Tunnel
Syndrome
Joint Capsular
Contractures (DIP,
PIP, MP joint, CMC)
Colles’ Fracture
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Dupuytren Contracture
Trigger Finger
Subungual Hematoma
Swan neck Deformity
Boutonniere deformity
Mallet finger deformity
Bowler’s Thumb
Jersey Finger
Handlebar Palsy
Ganglion Cyst
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Herniation of joint capsule or tendon sheath
Usually found on the back of the wrist but can
found anywhere a tendon is in the hand
May feel soft, rubbery, or very hard
Pain with the appearance of a lump
TX includes intense pressure or aspiration
followed by a compression pad
DeQuervain’s Disease
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Tenosynovitis or inflammation of the tendon sheath in the
wrist.
Occurs in Tunnel 1
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Tunnel narrows and pain is felt when the abductor pollicis
longus and extensor pollicis brevis moves in the tunnel
Seen in athletes whose sport requires great deal of wrist
ROM
Pain is an achy pain which radiates into forearm or hand
Special Test: Finklestein’s test
TX
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Immobilization, rest, cryotherapy, and antiinflammatory
medication
DeQuervain’s Disease
Fractured Scaphoid
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Falling on an
outstretched hand
At risk for avascular
necrosis
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Loss of blood supply
Often misdiagnosised
as a wrist sprain
Requires immediate
immobilization
Carpal Tunnel Syndrome
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Structures found in CT
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Inflammation of tendons and sheath
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Leads to compression of median nerve
Occurs in athletes who perform repeated
wrist flexion or direct trauma to tunnel
SX
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8 long finger flexor tendons
Their synovial sheath
The median nerve
Tingling, numbness in the thumb, index finger,
middle finger and palm of the hand
Atrophy of the thenar eminence
Weakness in thumb movement
Possitive Tinnel sign and Phalens test
TX
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Rest, immobilization, and NSAIDS
Can lead to injections of Corticosteriod and
possible surgical intervention
Colles Fracture
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Fracture of the Head of
the Radius with or
without the a fracture in
the ulna
Displacement is usually
dorsal
TX
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Closed reduction and
immobilization
Dupuytren’s Contracture
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Nodules form in palmer
aponeurosis
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Limits extension
Causes Flexion
Flexion deformity usually
found in ring and little
finger
Surgery is required
Trigger Finger /
Thumb
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Nodule forms on the Tendon
due to overuse
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Pain and funny clicking sound
with extension
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Tenosynovitis
Snapping is both palpable and
audible
Lump can be felt at the end of the
sheath
TX
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Immobilization, rest, cryotherapy,
and antiinflammatory medication
Steroid injections
Last option splinting finger in
extension
Subungual Hematoma
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Pooling of blood under the nail due to a
direct blow
TX
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Relieve pressure
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Drill through nail
Swan Neck Deformity
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Tearing of volar plate in
PIP joint due to severe
hyperextension force
Pain and swelling at PIP
joint
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Passively hyperextended
TX
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RICE
Splinted at 20 -30 degrees
of flexion for 3 weeks
Buddy tape
Boutonniere Deformity
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Rupture of the extensor tendon
dorsal to the middle phalanx
Trauma occurs to tip of the finger
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SX
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DIP extension
PIP Flexion
Severe pain and inability to extend
DIP joint
Obvious deformity and swelling
TX
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PIP is splinted into extension for 5
– 8 weeks
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While extended athlete is
encouraged to flex DIP
Mallet Finger Deformity
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AKA baseball or
basketball finger
Tearing of
extensor tendon
at the DIP joint
Ice and splint
Bowler’s Thumb
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Irritation to the ulnar digital nerve due to pressure
from the thumb hole
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SX
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Causes thickening and decrease sensation in the ulnar
digital nerve
Pain, tingling during pressure to the irritated area and
numbness
TX
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Padding thumbhole
Decrease amount of bowling
Jersey Finger
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Often occurs in the Distal
phalanx of the ring finger
Tearing of the flexor
digitorum profundus
tendon
Athlete is unable to flex
DIP joint
Unable to ever flex DIP
without surgery
Handlebar Palsy
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Compression of the
Ulnar nerve
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From absorption of
vibration and shock
through the handle bars
Causing numbness,
tingling or pain
Special Tests
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Flexor Digitorum Superficialis Test
Flexor Digitorum Profundus Test
Bunnel-Littler Test
Retinacular Test
Allen Test
Finklestein Test
Tinnel Sign for Carpal Tunnel Syndrome
Phalens Test
Referred Pain from shoulder and Elbow
Flexor Digitorum Superficialis Test
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Tests the Flexor
Digitorum Superficialis of
the 3rd digit
How to?
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Extend all fingers except the
one being tested
Then flex the finger in
question at the PIP joint
Positive Finding
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Unable to flex finger
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Means the FDS isn’t intact
or is torn
Flexor Digitorum Profundus Test
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Tests the Flexor Digitorum
Profundus of the 3rd digit
How to?
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Flex the finger in question at the
DIP joint
Positive Finding
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Unable to flex finger
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Means the FDP isn’t intact or is
torn
Bunnel-Littler Test
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Evaluates the tightness of intrinsic muscles
or joint capsular tightness
How?
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Hold MP joint in slight extension
Try to flex PIP joint
Positive finding
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Unable to bend = tightness in intrinsic muscles
Bunnel-Littler Test
Slight Extension of MP Joint
+ Flex PIP joint
Able to flex
Intrinsic muscles
aren’t tight
Unable to flex
Slight Flexion of MP
Joint + Flex PIP Joint
Able to flex
Tight Intrinsic
muscles
Unable to flex
Joint Capsular
tightness
Retinacular Test
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Tests Tightness in the Retinacular
Ligaments
How
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Hold PIP in neutral position and try and move the
DIP joint
To differentiate between Retinacular lig.
Tightness and joint capsular tightness
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Flex the PIP joint and repeat test
 If DIP then flexes the Retinacular lig. Is tight
 If the DIP still doesn’t flex then there is DIP joint capsular
tightness
Allen Test
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Determines whether or not the radial or
ulnar arteries are at full capacity
How?
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Instruct athlete to open and close his fist
quickly several times and then squeeze his
fist tightly so that venous blood is forced out
of palm
Place thumb over radial artery and index
finger over ulnar and press down
Have athlete open hand (palm should be
pale)
Release one artery while keeping pressure
on the other artery.
The hand should flush immediately
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If not part or all of that artery is blocked
Repeat with both arteries.
Finklestein Test
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Test for Tenosynovitis or
Dequervain’s disease in
tunnel 1
How?
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Tuck thumb in fist
Then ulnar deviate the wrist
Positive finding
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Sharp pain in the area of the
tunnel
Tinnel Sign for Carpal Tunnel
Syndrome
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Tap on the Transverse (volar) Carpal
Ligament
Positive finding
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Reoccurrence of symptoms
Phalens Test
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Testing for carpal tunnel
syndrome
How?
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Flex patient’s wrists to its
maximal degree and hold that
position for at least a minute
Positive Test
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Tingling of fingers
Pain or numbness