of the wrist and hands.
So we're gonna start by following
our mantra of look-feel-move
So we're gonna observe
the hands bilaterally,
you wanna check both surfaces - the
palmar and the dorsal surface.
What you wanna do is look for any sort of
sometimes you may have
nodules in the fingers,
sometimes you may have deviations
due to arthritis or degeneration
You wanna check the muscles and muscles tone,
Sometimes you have wasting of the muscles.
if you have the innervation of
the nerves innervating the hand.
So through observation, we check first for any
asymmetries then we're gonne feel and palpate
So when we're palpating, we're
gonna feel for the carpal bones
and see if there's any
We could feel for the muscles of the hand, you could
check the intactness of the fingers and the tendons,
sometimes I'll ask them to check wrist grip strength
and have them make a tight fist and don't let me pull.
and so that's a way to quickly
check grip strength in the hand
So we're gonna feel and see,
check our different landmarks
You do wanna check the
scaphoid and the lunate
cause these two bones are the most
commonly injured bones in the wrist
So be comfortable with understanding
your landmarks and where you're finding
your carpals and your
metacarpals and your phalanges.
After palpation, we're gonna
do some motion testing.
So at the wrist, we have in the
saggital plane, a flexion and extension
so you should be able to fully flex
the wrist and extend the wrist,
if there's any restrictions there, you
could note decreased extension or flexion
At the wrist we could also have ABduction going out
to the thumb and ADduction going towards the pinkie.
So another word for AB- and
ADduction of the wrist is also
radial deviation cause you're
deviating towards the radial bone
and ulnar deviation cause you're
going towards the ulnar bone
There's limited internal and
external rotation at the wrist
due to the the tendons and the
ligaments around the wrist.
You could also have motions
at the fingers and the thumb,
so make sure that all the motions at
the thumb and the fingers are intact
especially when the patients are complaining
of any specific finger joint pains
there is more flexion available than extension
to the attachments of the flexor tendons
but if the tendons are ever disrupted, that
could potentially decrease the amount of motion
or the finger may be
abnormally not able to move.
So if we find a motion
restriction at the wrist,
so if the patient is able to ulnar
deviate but not able to radial deviate,
then you name it for the freedoms that'll
be ulnar deviation wrist dysfunction
If a patient is able to flex but not fully extend
then that will be a wrist flexion dysfunction
so you wanna name the somatic dysfunction
based on the freedom of motion that you find
when you're motion testing the
wrist and hand and the fingers.
There are several tests that we could perform to help
narrow down certain pathologies in the hand and wrist.
So if someone has a fall or some sort
of trauma to the wrist and hand,
a lot of times there may be
injury to the scaphoid bone.
and so there's a test called the Watson's test, in this
test, check for the stability of the scaphoid bone.
So we start by really stabilizing the
scaphoid bone underneath our hands.
You wanna find the thumb and find the base of the
thumb then you'll find the bone underneath the thumb.
We're gonna hold on to the bone and then we're
gonna ask the patient with their fingers straight
to try to bring their hand
from ulnar to radial.
So I'm gonna hold this here and go ahead and try
to bring your hand from ulnar to radial. Good.
As the patient does that, that is checking for
the stability of the scapholunate ligaments
if there's pain, if the patient's unable to do
that, that will be a positive Watson's test.
If patients have pain in the
wrist and it's more central
and you're worried about something
going on with the lunate bone,
there's a test check for
So here, what we're gonna do is
we'er gonna do a Shuck test.
We're going to flex the wrist and then monitoring
over the lunate, we're gonna have the patient
try to extend their wrist or bring their
hands straight forward against resistance.
So as they do that, if there's
any pain in the area,
tenderness as they're trying to straighten out their wrist
then that might signify some sort of perilunate instability.
If you're concerned about the patency
of the vasculature in the hand,
our hand receives arterial supply
from the radial and ulnar side
and so if you you're doing a blood draw,
if you're doing arterial blood draw,
sometimes you wanna make sure that both sides
are patent, we could do an Allen's test.
So an Allen's test checks for the patency
of the blood vessels supplying the hand.
What we're gonna do is we're gonna
initially compress on those blood vessels
and have the patient open and
close their hands several times
or you could tell them
to kinda hold their fist
and after a couple of seconds the blood
will go through the venous return
and you're holding the
And so now, the patient's gonna open their
hand, you could see that it's more pale
and we're gonna
release one side.
So here, I release the ulnar side you
could see how the hand pinked up,
so that means the blood vessel is intact
'cause the blood is rushing through.
we could do the same thing for the opposite
side, go ahead and make a fist
and hold it
and open your hand and you see it's
pale and then I release the radial side
and you could see that it starts to pink up.
So the Allen's test is negative when the hand returns to
its normal color upon releasing each of the blood vessels.
If I release the blood vessel
and the hand does not pink up
then there may be an issue
with the blood vessel
and it may tell you to further investigate
or not to draw blood from that wrist.
Patients that complain of numbness and tingling in the
hand especially with the medial portion of the hand
numbs and tingling and maybe
they may have a thenar wasting
when it becomes more severe,
may suffer from carpal tunnel.
So carpal tunnel disease is a impingement of the
median nerve as it passes through the tunnel.
So the tunnel has a roof, the
attachments of the flexor retinaculum
include the scaphoid and the trapezium
and the hook of hamate and the pisiform
So across this ligament and underneath
it are a lot of your flexor tendons
and running along with those flexor
tendons is your median nerve.
and the median nerve comes and innervates the medial
aspect of your hand up to halfway of your forefinger.
So numbness and tingling in the hand due to certain
repetitive motions or injuries or swelling
could cause a carpal
So how could we assess for
carpal tunnel syndrome?
Well you could perform
a Tinel's test.
Tinel's test is when you tap over the median
nerve as it passes through the carpal tunnel
and if you tap and it recreates the
numbness and tingling and symptoms
then that is a positive test for
carpal tunnel syndrome.
So to perform it, you're gonna find that region
between the two bones where the carpal tunnel lies
and you're gonna apply a little bit of a gentle tap there
and if it recreates the pain, then that's a positive test.
Another test you could do to assess for carpal
tunnel syndrome is called the Phalen's test.
Here, we're gonna have the patient bring their
hands together and their elbows up to 90 degrees.
And so what that does is it really
compresses in that carpal region here
and the patient should be able to
hold this up for at least a minute.
If they're unable to hold this position for more
that a minute then that would be a positive test
especially if they're getting numbness, tingling in
the side that they were complaining of hand pain.
(You can put your hands down)
Patients that complain about pain along
their thumb especially along their
lateral aspect to their forearm may
have DeQuarvain's tenosynovitis.
So it is inflammation of the
tendon helping to move your thumb
has been definitely more common
now that people have been
texting or gaming or using more
precise motion with their thumb.
So to perform the test,
what we're going to do
is we're gonna have the patient take
their thumb and put it in their fist
and then we're gonna have them
slowly ulnar deviate their wrist.
So you're gonna take their thumbs in your hand
and kinda put your hand down towards the floor
There you go.
and so that is Finkelstein's test
and what you're doing is you're really stretching
that tendon and a positive test would be pain
or the inability for the patient
to try to ulnar deviate their hand.