So when we evaluate our patient, we
want to take a thorough history.
Most of the time we could tell what's going on with
their wrist and hand problems just by history alone.
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.
We have to take into consideration the
patient's age and other comorbidities
Patients with diabetes may have decreased
vascular and more neurovascular compromise.
So, when we start a physical exam,
we wanna start with observation.
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.
So we wanna take a look at the fingers in a
flexed and extended position and also at rest.
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.
When we ask the patient to flex their fingers, all
the fingers should point towards the scaphoid.
If it deviates to one side and the other, that should
increase your suspicion for some other pathology.
We could also check
for capillary refill.
Capillary refill is a way to evaluate
for blood supply to the hand.
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.
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.
If there is injuries to the autonomic
nervous system, to the nerves itself.
The hands could feel a
little bit more cold.
also look for any potential swelling and edema
in the hands and fingers or any nodules.
Secondary evaluation now
with the wrist and hand.
You wanna look more closely at the
individual joints in the hand.
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.
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.
When patients come in complaining of finger
pain or difficulty with moving their fingers,
we have to check for the
intactness of the ligaments.
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.
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.
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.
and here, you're gonna have to hold the fingers still so
that you could flex just the distal aspect of the finger.
If the tendon's intact,
they'll be able to do it.
If any of the ligaments are ruptured or injured, they won't
be ablen to perform flexion of the finger at that joint.
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.
So with the wrist, we could perform
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.
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.
Wrist flexion is controlled primarily by C7 and wrist
extension is controlled primarily with C6 nerve roots.
So with osteopathic diagnosis of the wrist and
hand, we make our diagnosis based on the freedoms.
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.
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.
You could also have AB- and ADduction dysfunctions
of the wrist and also the fingers itself.
So let's do a practice test question
with this knowledge.
We have a 45-year old, male, comes in with right
wrist pain after painting his house one week ago.
X-rays were negative and on examination, the right wrist could
extend 20 degrees and the left wrist could extend 70 degrees.
So what would be the somatic
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.
So let's do a another
practice test question.
We have a 70 year old female with a history of
rheumatoid arthritis who comes in with finger pain.
You note that on her right 2nd PIP joint
is swollen and radially deviated.
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.
And so here, we have radial
deviation with motion testing
that tells you that there's
resistance to ulnar deviations.
So you wanna name it for it's freedom and
thus it is a radial somatic dysfunction.
With our physical exam, we could also do
muscle strength testing.
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.
If there is weakness, then you have to try to
isolate the specific muscles that are weak.