Examination and Testing of the Wrist and Hand

00:01 So when we evaluate our patient, we want to take a thorough history.

00:05 Most of the time we could tell what's going on with their wrist and hand problems just by history alone.

00:13 We want to try to ask patients whether or not they had any sort of mechanical injury or trauma that will often point to whether or not there's a ligamentous injury or potential bone injury or fracture.

00:27 We have to take into consideration the patient's age and other comorbidities Patients with diabetes may have decreased vascular and more neurovascular compromise.

00:41 So, when we start a physical exam, we wanna start with observation.

00:45 A lot of times, when patients have wrist and hand injuries, there might be things that we could pick up from observation that is grossly asymmetric.

00:53 So we wanna take a look at the fingers in a flexed and extended position and also at rest.

00:59 When we're looking at the hand and patients have any sort of tendon rupture, that might demonstrate and show fingers that are stucked in a flexed or extended position.

01:12 When we ask the patient to flex their fingers, all the fingers should point towards the scaphoid.

01:18 If it deviates to one side and the other, that should increase your suspicion for some other pathology.

01:24 We could also check for capillary refill.

01:28 Capillary refill is a way to evaluate for blood supply to the hand.

01:33 And so, in order to perform capillary refill test, what you want to do is to place pressure on the nail bed and when you put that pressure on the nail bed, the nail bed should become more pale and when you release the pressure, the nail bed should return to a pink, red state indicating that there's proper blood flow to the fingers.

01:55 Physical exam could also, you could also note on physical exam whether or not there's changes in color of the hand and also temperature.

02:04 If there is injuries to the autonomic nervous system, to the nerves itself.

02:08 The hands could feel a little bit more cold.

02:11 also look for any potential swelling and edema in the hands and fingers or any nodules.

02:18 Secondary evaluation now with the wrist and hand.

02:21 You wanna look more closely at the individual joints in the hand.

02:25 You could try to assess for pain and look for specific tendon whether or not they're intact by asking patients to do specific motions in the fingers.

02:35 And so you wanna look on both sides of the hand, both the palmar and distal surface and make that everything looks like they're aligned.

02:44 When patients come in complaining of finger pain or difficulty with moving their fingers, we have to check for the intactness of the ligaments.

02:54 And so, our flexor ligaments are attached to our fingers, the flexor digitorum superficialis does flexion of the fingers at the proximal interphalangeal or the PIP joint.

03:07 And so to check for that, we're gonna ask the patient to flex their finger and they should be able to flex their finger.

03:13 If we're looking more at the flexor digitorum profundus, here we're gonna ask the patient to just try to flex the distal interphalangeal joint or the DIP.

03:24 and here, you're gonna have to hold the fingers still so that you could flex just the distal aspect of the finger.

03:29 If the tendon's intact, they'll be able to do it.

03:33 If any of the ligaments are ruptured or injured, they won't be ablen to perform flexion of the finger at that joint.

03:40 To look at the extensor tendons, when the extensor tendons are injured or ruptured, what you'll usually will see is a gross deformity of the finger where the finger will be stuck in flexion and so if you have a rupture of the extensor digitorum communis or the distal slip you're gonna have flexion of the distal interphalangeal joint and if you have rupture of the extensor digitorum communis, you're gonna have a flexion at the proximal interpalangeal joint.

04:16 So with the wrist, we could perform motion testing.

04:21 And so usually, with range of motion testing in the wrist, we could see radial deviation which is really ABduction of the wrist to about 20 degress.

04:33 Ulnar deviation which is ADduction to about 30 degrees and then you also have wrist flexion to about 80 degrees and wrist extension to about 70 degrees.

04:46 Wrist flexion is controlled primarily by C7 and wrist extension is controlled primarily with C6 nerve roots.

04:57 So with osteopathic diagnosis of the wrist and hand, we make our diagnosis based on the freedoms.

05:06 and so if I find a specific restriction on the wrist and fingers, we name the somatic dysfunction in the opposite direction of the restriction.

05:15 So we could have flexion and extension somatic dysfunctions of the wrist We could have very slight internal-external somatic dysfunctions of the wrist but there's not a lot of internal-external rotation of the wrist in itself but sometimes you'll have internal-external rotation somatic dysfunction of the fingers based on different changes of the joint or injuries.

05:39 You could also have AB- and ADduction dysfunctions of the wrist and also the fingers itself.

05:47 So let's do a practice test question with this knowledge.

05:51 We have a 45-year old, male, comes in with right wrist pain after painting his house one week ago.

05:56 X-rays were negative and on examination, the right wrist could extend 20 degrees and the left wrist could extend 70 degrees.

06:04 So what would be the somatic dysfunction present? So here, we have a right wrist extension restriction compared to the left and so we name it for the freedom and so we have a right wrist flexion somatic dysfuction.

06:21 So let's do a another practice test question.

06:23 We have a 70 year old female with a history of rheumatoid arthritis who comes in with finger pain.

06:29 You note that on her right 2nd PIP joint is swollen and radially deviated.

06:35 On motion testing it resists ulnar deviation. What would be the somatic dysfunction present? So here we have a right 2nd PIP joint radial somatic dysfunction So remember we wanna name the somatic dysfunction for it's freedom and here, the patient with rheumatoid arthritis and usually with rheumatoid arthritis patients will have changes to their fingers and you'll see some changes to the joints and sometimes motion changes at the different joints.

07:08 And so here, we have radial deviation with motion testing that tells you that there's resistance to ulnar deviations.

07:16 So you wanna name it for it's freedom and thus it is a radial somatic dysfunction.

07:25 With our physical exam, we could also do muscle strength testing.

07:28 Muscle strength testing is a way to detect any sort of damage to the nerves or the muscles itself A quick screening is to just ask the patients to squeeze your finger and see if there's any weakness.

07:43 If there is weakness, then you have to try to isolate the specific muscles that are weak.