Wrist and Hand

Wrist and
Hand
ALIVIA, AGILA
BASSIG, MATT JOSEPH
DE LEON, RAE LAURA
LEONG, SUZETTE
ARAVIND MB
RAJU, CHRISTEENA
SAM SOLIMAN, JENNYLYN
TORIO, KRISELDA MAY
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Bony Structures
And Joints Of The
Hand

BONES of
WRIST
AND
HANDS

Ossificatio
n of Bones
of the
Hands

Radiographs of the wrist and hand are commonly used to
assess skeletal age.
Each carpal bone usually ossifies from one center
postnatally .
The centers for the capitate and hamate appear first.
The shaft of each metacarpal begins to ossify during fetal
life, and ossification centers appear postnatally in the
heads of the four medial metacarpals and in the base of
the 1st metacarpal.
 By age 11, ossification centers of all carpal bones are
visible.
Ossification of Bones of the Hand
1.3 years old

11 years old
4.4 years old 6
JOINTS OF THE HAND

Falls on the Outstretched Hand
scaphoid
• Forces are transmitted from the scaphoid to the
distal end of the radius, from the radius across the distal end of radius
interosseous membrane to the ulna, and from the
ulna to the humerus; through the glenoid fossa of interosseous membrane
the scapula to the coracoclavicular ligament and
the clavicle; and finally, to the sternum. ulna
• If the forces are excessive, different parts of the
upper limb give way under the strain. humerus
• Young child- posterior displacement of the distal
radial epiphysis; glenoid fossa
• Teenager- the clavicle might fracture coracoclavicular ligament
• Young adult the scaphoid is commonly fractured and clavicle
• Elderly- distal end of the radius is fractured about 1
in. (2.5 cm) proximal to the wrist joint (Colles’ sternum
fracture).
8
COLLES’ FRACTURE
• A fracture of the distal end of the radius resulting
from a fall on the outstretched hand.
• Commonly occurs in >50 years.
• The force drives the distal fragment posteriorly and
superiorly, and the distal articular surface is inclined
posteriorly.
• This posterior displacement produces a posterior
bump, sometimes referred to as the “dinner-fork
deformity” because the forearm and wrist resemble
the shape of that eating utensil.
• Failure to restore the distal articular surface to its
normal position will severely limit the range of
flexion of the wrist joint.
SMITH’S FRACTURE
• A fracture of the
distal end of the
radius and occurs
from a fall on the
back of the hand.
• It is a reversed
Colles’ fracture
because the distal
fragment is
displaced anteriorly.
BARTON FRACTURE
• Volar-type Barton's (Reverse Barton) is a fracture-dislocation of
the volar rim of the radius. This type is the most common. It is a
type II Smith’s Fracture: oblique distal intra-articular radial fracture
• Dorsal-type Barton's is a fracture-dislocation of the dorsal rim of
the radius. It is similar to Colles’ Fracture. There is usually
associated dorsal subluxation/dislocation of the radiocarpal joint.
• Dislocation of the radiocarpal joint is the hallmark of Barton's

fractures.
• These are shear type fractures of the distal articular surface of the
radius with translation of the distal radial fragment and the carpus.
• These fractures have a great tendency for redislocation and
malunion.

A. Colles’ Fracture B. Smith’s
Fracture
CHAUFFEUR FRACTURE
• Intra-articular Radial styloid fracture
• Also called Hutchinson's or Backfire fracture
• These injuries are sustained either from direct trauma
typically a blow to the back of the wrist or from
forced dorsiflexion and abduction.
• It accounts for its name; trying to start an old-
fashioned car with a hand crank sometimes resulted
in the crank rapidly spinning backwards (backfire) out
of the driver's grasp and striking the back of the
wrist 5.
• The later occurs as the scaphoid forcibly impacts upon
the radial styloid and can be considered an avulsion
fracture with the radiocarpal ligaments remaining
attached to the radial styloid
Die-Punch Fracture
• A depression fracture of the lunate fossa
of the distal radius.
• It is the result of a transverse load on
the distal radius through the lunate
• Result from an axial loading force
• It is by definition depressed or impacted
and is named after the machining
technique of shearing a shape,
depression or hole in a material with a
die implement or cutter used in the
tool-and-die trade.
Classification of Distal
Radius Fracture

GALEAZZI FRACTURE
• Fracture of distal 3rd of radius with dislocation of DRUJ

• Cause: Fall on outstretched hand with forearm in pronation
• Results to Anterior interosseous nerve palsy
• Sometimes associated with wrist drop due to injury to radial nerve,
extensor tendon or muscles
BOXER’S FRACTURE
• minimally comminuted, transverse
fractures of the 5th metacarpal and
are the most common type
of metacarpal fracture.
• Impaction injury (axial loading of the
5th metacarpal) almost always result
as a consequence of a direct blow
with a clenched fist against a solid
surface.
• Young adult males are by far the
most commonly affected group
BOXER’S KNUCKLE
• Disruption to the sagittal bands of
the extensor hood, particularly over the
metacarpophalangeal (MCP) joint.
• Result when a clench fisted hand strikes an
object in a traumatic situation
• Less often it can also result in a non traumatic
situation such in the case of RA
• The ulnar and radial sagittal bands exert
tensile forces in opposite directions during
flexion, which keeps the extensor tendon in
apposition with the metacarpal bone.
• Inability to fully extend the MCP joint and a
palpable defect to the side of the extensor
tendon.
• Dislocation of the lunate bone occasionally occurs in young adults
who fall on the outstretched hand that causes hyperextension of the
wrist joint. Involvement of the median nerve is common.
• Fractures of the metacarpal bones can occur as a result of direct
violence, such as the clenched fist striking a hard object. The fracture
always angulates dorsally.
• The “boxer’s fracture” commonly produces an oblique fracture of the
neck of the fifth and sometimes the fourth metacarpal bones. The distal
fragment is commonly displaced proximally, thus shortening the finger
posteriorly.
19
Axial Load Test
• The patient sits while the examiner
stabilizes the patient’s wrist with one
hand.
• With the other hand, the examiner
carefully grasps the patient’s thumb
and applies axial compression.
• Positive test: Pain and/or crepitation,
indicate fracture of metacarpal or
adjacent carpal bones or joint
arthrosis.
• A similar test may be performed for
the fingers.
Dorsal Capitate Displacement
Apprehension Test
• This test is used to determine the stability of the
capitate bone.
• The patient sits facing the examiner. The examiner
holds the forearm (radius and ulna) with one hand.
The thumb of the examiner’s other hand is placed
over the palmar aspect of the capitate while the
fingers of that hand hold the patient’s hand in
neutral (no flexion or extension, no radial or ulnar
deviation) and apply a counter pressure when the
examiner pushes the capitate posteriorly with the
thumb
• Positive test: Reproduction of the patient’s
symptoms, apprehension, or pain. A click or snap
may also be heard when pressure is applied.
KIENBÖCK’S DISEASE
• Avascular necrosis of the lunate,
leading to death of the bone.
• The lunate is a central bone in the wrist
that is important for proper movement
and support of the joint. It works
closely with the 2 forearm bones
(radius and ulna) to help the wrist
move.
• Greatest pain over dorsal scapholunate
area, accentuated with dorsiflexion
• X-ray shows widening of scapholunate
joint space by at least 3 mm

Fracture of the Scaphoid bone
• common in young adults
• unless treated effectively, the fragments will not
unite, and permanent weakness and pain of the
wrist will result, with the subsequent
development of osteoarthritis.
• The blood vessels to the scaphoid enter its
proximal and distal ends, although the blood
supply is occasionally confined to its distal end.
If the latter occurs, a fracture deprives the
proximal fragment of its arterial supply, and this
fragment undergoes avascular necrosis.
• Deep tenderness in the anatomic snuffbox after
a fall on the outstretched hand in a young adult
makes one suspicious of a fractured scaphoid.
23
Scaphoid Stress Test
• The patient sits and the examiner holds the
patient’s wrist with one hand so that the
thumb applies pressure over the distal pole
of the scaphoid. The patient then attempts
to radially deviate the wrist.
• Normally, the patient is unable to deviate
the wrist.
• Positive test: Excessive laxity is present, the
scaphoid is forced (shifted) posteriorly out
of the scaphoid fossa of the radius with a
resulting “clunk” and pain
• Indicates scapholunate instability or a
scaphoid fracture
Bennett’s fracture
• a fracture of the base of the
metacarpal of the thumb caused
when violence is applied along the
long axis of the thumb or the
thumb is forcefully abducted. The
fracture is oblique and enters the
carpometacarpal joint of the
thumb, causing joint instability.
26
Finger Extension or “Shuck” Test
• The patient is placed in sitting. The
examiner holds the patient’s wrist
flexed and asks the patient to
actively extend the fingers against
resistance-loading the radiocarpal
joints.
• Positive test: Pain for radiocarpal
or midcarpal instability, scaphoid
instability, inflammation, or
Kienböck disease

Linscheid Test
• This test is used to detect
ligamentous instability of the second
and third carpometacarpal joints.
• The examiner supports the
metacarpal shafts with one hand.
With the other hand, the examiner
pushes the metacarpal heads
dorsally, then palmarly
• Positive test: Pain localized to the
carpometacarpal joints

Lunotriquetral Ballottement (Reagan’s)
Test
• This test is used to determine the
integrity of the lunotriquetral ligament.
• The examiner grasps the triquetrum
between the thumb and second finger of
one hand and the lunate with the thumb
and second finger of the other hand. The
examiner then moves the lunate up and
down (anteriorly and posteriorly)
• Positive test: laxity, crepitus, or pain

Murphy’s Sign
• The patient is asked to make a fist.
• Normally, the third metacarpal
would project beyond (or further
distally) the second and fourth
metacarpals.
• Positive test: Head of the third
metacarpal is level with the second
and fourth metacarpals, indicative
of a lunate dislocation.

“Piano Keys” Test
• The patient sits with both arms in pronation.
The examiner stabilizes the patient’s arm with
one hand so that the examiner’s index finger
can push down on the distal ulna. The
examiner’s other hand supports the patient’s
hand. The examiner pushes down on the distal
ulna as one would push down on a piano key.
• The results are compared with the
nonsymptomatic side.
• Positive test: difference in mobility and the
production of pain and/or tenderness. This
indicates instability of the distal radioulnar
joint

Sitting Hands (Press) Test
• The patient places both hands on the arms of
a stable chair and pushes off, suspending the
body while using only the hands for support.
• This test places a great deal of stress (axial
ulnar load) at the wrist (and elbow) and is too
difficult to do in the presence of significant
wrist synovitis or wrist pathology.

Thumb Grind Test
• The examiner holds the patient’s hand
with one hand and grasps the patient’s
thumb below the metacarpophalangeal
joint with the other hand.
• The examiner then applies axial
compression and rotation to the
metacarpophalangeal joint.
• Positive test: Pain
• Indicative of degenerative joint disease
in the metacarpophalangeal or
metacarpotrapezial joint

Ulnar Fovea Sign Test
• The patient stands or sits. The examiner presses a
thumb or finger into the interval or depression
(fovea) between the ulnar styloid process and the
flexor carpi ulnaris tendon between the anterior
surface of the ulnar head and the pisiform.
• Positive test: Pain is replicated or the area is very
tender compared to the unaffected side.
• The pain is believed to be due to distal radioulnar
ligaments and ulnotriquetral ligament.
Ulnotriquetral ligament tears are commonly
associated with a stable distal radioulnar joint and
fovea disruptions are associated with an unstable
distal radioulnar joint.

Muscles of the
Hands

SUPERFICIAL MUSCLES IN THE
ANTERIOR COMPARTMENT of
the FOREARM
•Flexor carpi ulnaris

•Palmaris longus
•Flexor carpi radialis
•Pronator teres
They all originate from a common

tendon, which arises from the medial
epicondyle of the humerus.
MUSCLES AND
MOVEMENTS
WRIST FLEXION:
• Flexor carpi ulnaris
• Flexor carpi radialis
• Palmaris longus
• Flexor digitorum
superficialis and profundus
PALMARIS LONGUS
• In between the Flexor Carpi
Ulnaris and the Flexor Carpi
Prime movers Radialis muscles.
aided by palmaris • Almost 10% of the population
longus and the could be lacking this muscle
flexors of fingers either in one forearm (unilateral)
or both the forearms (bilateral)
and thumb
• Absence of the palmaris longus
does not have an effect on grip
strength.

WRIST EXTENSION:
Extensor carpi
radialis longus
Extensor carpi
radialis brevis
Extensor carpi
ulnaris
CTO: Lateral
epicondyle
SUPINATOR MUSCLE:
Biceps Brachii
SUPINATION
• The anatomical position of the
hand is a convenient standard for
studying structural relationships.
• Supination movement of rotating
the forearm into a palm up
position.

PRONATION
• Pronator teres
• Pronator quadratus
• Brachioradialis

Tests for Tendons and Muscles
• Finkelstein Test
• Used to determine the presence of de Quervain or
Hoffman disease, a oaratenonitis in the thumb
• The patient makes a fist with the thumb inside the
fingers.
• The examiner stabilizes the forearm and deviates the
wrist toward the ulnar side.
• A positive test is indicated by pain over the abductor
pollicis longus and extensor pollicis brevis tendons at
the wrist and is indicative of a paratenonitis of these
two tendons.
• The test can cause some discomfort in normal
individuals, the examiner should compare the pain
caused on the affected side with that of the normal
side. Only if the patient’s symptoms are produced is
the test considered positive.
42
Tests for Tendons and Muscles
Sweater Finger Sign.
• The patient is asked to make a
fist. If the distal phalanx of one of
the fingers does not flex, the sign
is positive for a ruptured flexor
digitorum profundus tendon. It
occurs most often to the ring
finger.
43
MOVEMENT
OF THE
THUMB
MUSCLES INVOLVED
45
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THENAR
MUSCLE
S
46
HYPOTHENAR
MUSCLES
MOVEMENT OF THE LITTLE

FINGER:
• Abduct and flexes
little finger
• Pulls fifth metacarpal
forward as in cupping
the palm
47
INTRINSIC MUSCLES OF THE
HAND
• 4 Lumbricals (Flexion)
• 4 Dorsal interossei ( Abduction)
• 3 Palmar interossei (Adduction)

SPECIAL STRUCTURE NERVES
50
DEEP FASCIA Palmar aponeurosis
 Flexor Retinaculum
Deep fascia of the wrist and palm is
is a strong, fibrous band serves as anterior wall
thickened to form the flexor retinaculum and
of carpal tunnel. It transmits the flexor tendons of
the palmar aponeurosis.
the digits and the median nerve.
51
DUPUYTREN CONTRACTURE
 Localized thickening and contracture of
palmar aponeurosis.
• Starts near the root of the ring finger and
draws that finger into the palm, flexing it
at the metacarpophalangeal joint. Later,
the condition involves the little finger.
• In long-standing cases, the pull on the
fibrous sheaths of these fingers results in
flexion of the proximal interphalangeal
joints.
52
CARPAL TUNNEL
The channel contains
the sheath and
flexor tendons of
the forearm
muscles and the
median nerve.
Within the tunnel the
tendons of flexor
digitorum
superficialis lie
anterior to those of
flexor digitorum
profundus.
53
Carpal Tunnel Syndrome
• a burning pain or “pins and needles” along the distribution of the median nerve
to the lateral three and a half fingers and weakness of the thenar muscles.
• It is produced by compression of the median nerve within the tunnel. The exact
cause of the compression is difficult to determine, but thickening of the synovial
sheaths of the flexor tendons or arthritic changes in the carpal bones are thought
to be responsible in many cases.
• No paresthesia occurs over the thenar eminence because this area of skin is
supplied by the palmar cutaneous branch of the median nerve, which passes
superficially to the flexor retinaculum.
• Relieved by decompressing the tunnel by making a longitudinal incision through
the flexor retinaculum.
54
CARPAL TUNNEL SYNDROME
THUMB ABDUCTION-To test thumb abduction, ask the patient to raise the
thumb straight up as you apply downward resistance
• Weakness on
thumb abduction
is a positive test
• Abductor pollicis
longus – median
nerve
55
Test for Phalen’s sign for median nerve
compression
• Ask the patient to hold the wrists in
flexion for 60 seconds. Alternatively,
ask the patient to press the backs of
both hands together to form right
angles
• A positive test is indicated by
tingling in the thumb, index finger,
and middle and lateral half of the
ring finger and is indicative of carpal
tunnel syndrome caused by
pressure on the median nerve
56
Reverse Phalen’s (Prayer) Test
• The examiner extends the patient’s
wrist while asking the patient to grip the
examiner’s hand.
• The examiner then applies direct
pressure over the carpal tunnel for 1
minute.
• The test is also described by having the
patient put both hands together and
bringing the hands down toward the
waist while keeping the palms in full
contact, causing extension of the wrist.
• A positive test is indicated by tingling in
the thumb, index finger, and middle and
lateral half of the ring finger and is
indicative of median nerve pathology.
57
TINEL’S SIGN for median nerve compression by
tapping lightly over the course of the median nerve
in the carpal tunnel
 Aching and numbness

in the median nerve
distribution is a
positive test.
58
Test for Neurologic Dysfunction
Tethered Median Nerve Stress Test
• The patient stands or sits with the
elbow flexed and forearm supinated
with wrist in slight extension.
• The examiner then hyperextends the
index finger at the distal
interphalangeal joint.
• Anterior radiating forearm pain is felt,
the test is considered positive for
median nerve pathology. Positive
results are more likely in chronic
conditions.
59
ULNAR TUNNEL SYNDROME
also known as Guyon's canal
syndrome or Handlebar palsy,
is caused by entrapment of the
ulnar nerve in the Guyon canal as
it passes through the wrist.
Relatively rare peripheral ulnar
neuropathy which involves injury
to the distal portion of the ulnar
nerve as it travels through a
narrow anatomic corridor at the
wrist.
60
Cubital Tunnel Syndrome
• Involves pressure or
stretching of ulnar nerve,
which passes through the
cubital tunnel
• Signs and symptoms: pins
and needles –felt in ring and
small fingers, hand pain,
weak grip and clumsiness
due to muscle weakness
• Often felt when elbow is
bent for a long time

Upper Lesions of the Brachial Plexus
(Erb–Duchenne Palsy)
• This results from excessive displacement of
the head to the opposite side & depression
of the shoulder on the same side.
• This causes excessive traction or even
tearing of C5 & C6 roots
• The limb will hang limply by the side,
medially rotated by the unopposed
sternocostal part of the pectoralis major;
the forearm will be pronated because of
loss of the action of the biceps.
• The position of the upper limb in this
condition has been likened to that of a
porter or waiter hinting for a tip. 62
Lower Lesions of the Brachial Plexus
(Klumpke Palsy)
• Usually are traction injuries caused by excessive
abduction of the arm, as occurs in the case of a
person falling from a height clutching at an object to
save himself or herself.
• Nerve fibers from this segment run in the ulnar and
median nerves to supply all the small muscles of
the hand.
• Hand has a clawed appearance caused by
hyperextension of the MCP joints and flexion of the
interphalangeal joints.
• Extensor digitorum is unopposed by the lumbricals
and interossei and extends the MCP joints; Flexor
digitorum superficialis and profundus are
unopposed by the lumbricals and interossei and flex
the middle and terminal phalanges, respectively.
63
8

Test for Neurologic Dysfunction
Froment’s “Paper” Sign.

• The patient attempts to grasp a piece of paper between the thumb and index
finger. When the examiner attempts to pull away the paper, the terminal phalanx
of the thumb flexes because of paralysis of adductor pollicis muscle, indicating a
positive test.
• If at the same time, the MCP joint of the thumb hyeperextends, the
hyperextension is noted as positive Jeanne’s sign.
• Both tests, if positive, are indicative of ulnar nerve paralysis. 65
EXTENSOR
RETINACULUM
 is a strong, fibrous
band that extends
obliquely across the
back of the wrist
 It prevents
bowstringing of the
tendons across the
wrist joint
66
Techniques of
Physical Examination
• Patient Profile( demographics)
• Patient History
• Inspection
• Palpation
Wrist
a. Range of motion
b.Maneuvers
Fingers and Thumbs
a. Range of motion
67
INSPECTIO
N

INSPECT THE VENTRAL AND DORSAL ASPECT OF HAND AND WRIST
• Observe the hand in resting position and patterns of movement

• Compare the symmetry, contours of soft tissue or note any deformity.
• It is also important to assess the patient’s reaction to the appearance
of hand deformities as part of functional assessment.

PHYSICAL EXAMINATION
INSPECTION
 Smooth and natural- observe for
motion
 When the fingers are relaxed they
should be slightly flexed
 Fingernail edges should be in parallel.
70
Normal Functional Position of the
Hand
When it is about to grasp an object
between the thumb and index finger.
The forearm is in the semiprone position,
the wrist joint is partially extended
(more so than in the position of rest),
and the fingers are partially flexed, the
index finger being flexed as much as the
others. The metacarpal bone of the
thumb is rotated in such a manner that
the plane of the thumbnail lies parallel
with that of the index finger, and the
pulp of the thumb and index finger are in
contact.

Normal Resting Position of the Hand
Posture adopted by the hand
when the fingers are at rest
and the hand is relaxed. The
forearm is in the semiprone
position; the wrist joint is
slightly extended; the 2nd to
5th fingers are partially
flexed, although the index
finger is not flexed as much
as the others; and the plane
of the thumbnail lies at a
right angle to the plane of
the other fingernails.
NORMAL HANDS PALSY
FLEXOR TENDON
DAMAGE
Guarded movement suggests
injury. Abnormal finger alignment
is seen in flexor tendon damage.
73
 Inspect the palmar and dorsal surfaces of the wrist and
hand carefully for swelling over the joints
Swelling over joints
• Diffuse swelling- common in arthritis or infection
• Local swelling- local swelling suggests a ganglion
Signs of trauma
• Laceration
• Erythema
• Puncture marks
• Burns
75
GANGLION
• Localized Painless Swelling on the
Dorsum
• Nontender swelling à tendon
sheaths/joints
• Cyst with synovial fluid
• Prominent on flexion, obscure on
extension
• protrusion cyst of the joint capsule
usually seen on the dorsum of the
naviculo-lunate joint
• Painless, round, sessile, tense,
Translucent more prominent in flexion 76
• Note any deformities of Wrist hand, finger bones
and any angulation
• OSTEOARTHRITIS (Degenerative Joint Disease)

Heberden nodes (DIP joints)
Bouchard nodes (PIP joints)
• Usually hard and painless, they affect middle-

ages or older adults.
• Flexion and deviation deformities may develop.
• MCP joints are spared.
• In RA, inspect for symmetric deformity in the PIP,
MCP, and wrist joints;

RHEUMATOID ARTHRITIS
Acute Rheumatoid Arthritis

• Tender, painful, stiff joints, usually with symmetric involvement on
both sides of the body.
• Distal interphalangeal (DIP), metacarpophalangeal (MCP), and wrist
joints are the most frequently affected.
• Note the fusiform or spindle-shaped swelling of the PIP joints in
acute disease.
Chronic Rheumatoid Arthritis

• There is swelling and thickening of the MCP and PIP joints.
• Range of motion becomes limited, and fingers may deviate toward
the ulnar side.
• The interosseous muscles atrophy.
• The fingers may show “swan neck” deformities.
• Less common is a boutonnière deformity
• Rheumatoid nodules are seen in the acute or the chronic stage.
78
CHRONIC TOPHACEOUS GOUT
• Urate crystal deposits, often with surrounding inflammation, cause

deformities in subcutaneous tissues, bursae, cartilage, and subchondral bone
that mimic RA and OA.
• Joint involvement is usually less symmetric than in RA.
• Knobby swellings around the joints ulcerate and discharge white chalk-like
urates.
Observe the contours of the palm,
namely the Thenar & Hypothenar
Eminences
 Median nerve compression

 Thenar Atrophy- Carpal tunnel
syndrome (median nerve
compression).
 Ulnar nerve compression
 Hypothenar Atrophy
80
ACUTE TENOSYNOVITIS
• Tenosynovitis is an infection of a synovial sheath.
• It most commonly results from the introduction of
bacteria into a sheath through a small penetrating
wound, such as that made by the point of a needle or
thorn.
• Causes: local injury, overuse, infection
• Causative agents : Staph, Strep, disseminated
gonorrhea and Candida albicans
• From distal phalanx to level of MCP –finger is in slight
flexion extension is very painful.
81
Trigger Finger • Painless nodule (NOTTA’s
Nodule)
• palpable and audible snapping
when a patient is asked to flex
and extend the fingers
• caused by the presence of a
localized swelling of one of
the long flexor tendons that
catches on a narrowing of the
fibrous flexor sheath anterior
to the MCP joint. It may take
place either in flexion or in
extension.
• Trigger thumb- more common
in young children
82
FELON
• The pulp space of the fingers is a closed
fascial compartment situated in front of the
terminal phalanx of each finger.
• Injury to the fingertip may result in
infection of the enclosed fascial spaces,
usually from Staphylococcus aureus.
Bacteria are usually introduced into the
space by pinpricks or sewing needles.
• Severe pain, localized tenderness, swelling,
and dusky redness are characteristics.

PALPATION

PALPATION
• At the wrist, palpate the
distal radius and ulna on
the lateral and medial
surfaces.
• Palpate the groove of
each wrist joint with your
thumbs on the dorsum of
the wrist, your fingers
beneath it.
• Note any swelling,
bogginess, or tenderness.
85
• Tenderness over the distal
radius occurs in COLLES’
FRACTURE from a fall,
especially in patients with
osteoporosis. Any
tenderness or bony step offs
are suspicious for fracture.
• Swelling and/or tenderness

suggests RHEUMATOID
ARTHRITIS if bilateral and of
several weeks’ duration.
86
Palpate the radial
styloid bone and
the anatomical
snuffbox.
• Tenderness over the

extensor and abductor
tendons of the thumb at
the radial styloid suggests
de Quervain’s
tenosynovitis and
gonococcal tenosynovitis.
• Tenderness over the
“snuffbox” suggests
scaphoid fracture.
87
PAINFUL SWELLING IN THE ANATOMIC
SNUFFBOX
• Inflammation in the tendon sheaths of the extensor pollicis longus
and brevis
• Pain in the region of the snuffbox.
• Pain with pinching, thumb extension and ulnar deviation of the wrist.
• This pain may be transmitted down the thumb or toward the elbow.
• Passive extension of the thumb is painless.
• Crepitus may be felt or auscultated over the tendon sheath during
thumb flexion-extension.

Palpate the eight carpal bones lying distal to the wrist joint, and then each of
the five metacarpals and the proximal, middle, and distal phalanges.
Compress the MCP joints by squeezing the hand from each side between the
thumb and fingers
 Synovitis in the MCPs is painful with

this pressure—a point to remember
when shaking hands.
 The MCPs are often boggy or tender
in rheumatoid arthritis, but are rarely
involved in osteoarthritis. Pain with
compression also occurs in
posttraumatic arthritis.

Palpate the medial and lateral aspects of each PIP joint between your thumb
and index finger, again checking for swelling, bogginess, bony enlargement, or
tenderness.
 Pain at the base of the thumb

-carpometacarpal arthritis
 Hard dorsolateral nodules on
the DIP joints (Heberden’s
nodes)- OA, Psoriatic arthritis

91
Wrists: Range of Motion and Maneuvers
93
Conditions that impair range of motion
include arthritis, tenosynovitis, and
Dupuytren’s contracture
MANEUVERS:
• Note the distribution of the
median, radial, and ulnar nerve
innervations of the wrist and hand.
• Remember to assess more proximal
causes of wrist and hand pain
arising in the cervical cord and
nerve roots.
94
You can test sensation as follows:
 Pulp of the index finger—median nerve
 Pulp of the fifth finger—ulnar nerve
 Dorsal web space of the thumb and index finger—radial nerve
 Decreased sensation in the median nerve distribution characterizes

carpal tunnel syndrome.
95
Tests for Circulation and Swelling
Allen Test.
• The patient is asked to open and close the hand
several times as quickly as possible and then
squeeze the hand tightly.
• The examiner’s thumb and index finger are placed
over the radial and ulnar arteries, compressing
them. The patient then opens the hand while
pressure is maintained over the arteries. One
artery is tested by releasing the pressure over
that artery to see if the hand flushes. The other
artery is then tested in a similar fashion. Both
hands should be tested for comparison.
• This test determines the patency of the radial and
ulnar arteries and determines which artery
provides the major blood supply to the hand.
96
Assessment of
Range of Motion of
the hand
97
Functional Wrist and
Hand Scan
• Wrist flexion and extension
• Wrist ulnar and radial deviation
• Making a standard fist
• Making a hook grasp
• Making a straight fist
• Pulp-to-pulp thumb to all fingers
pinch
• Tip-to-tip thumb to all fingers pinch
98
FUNCTIONAL HAND GRIP
• Thumb is the most important digit.
• Its relation with the other digits, it’s mobility and the force it can bring, its
loss can affect hand function greatly.
• Index finger: second most important because of it’s musculature,
strength and interaction with the thumb. It’s loss greatly affect lateral and
pulp to pulp pinch and power grip
• Middle finger: strongest in flexion-important for both precision and
power grip
• Ring finger-least functional role in the hand
• Little finger-peripheral position greatly enhances power grip-affects the
capacity of the hand and holds objects against hypothenar eminence.
99
Hand Grip. Test hand grip strength by asking the patient to grasp your second
and third fingers. This tests function of wrist joints, the finger flexors, and the
intrinsic muscles and joints of the hand.
 Wrist pain and grip weakness - de Quervain’s Tenosynovitis

 Decreased grip strength - Arthritis, Carpal tunnel syndrome,
Epicondylitis, and Cervical radiculopathy
Thumb Movement. Test the thumb function if there is wrist pain by asking
the patient to grasp the thumb against the palm and then move the wrist toward
the midline in ulnar deviation (commonly called Finkelstein’s test).
 Pain - de Quervain’s Tenosynovitis (inflammation of the Abductor Pollicis

Longus & Extensor Pollicis Brevis tendons and the tendon sheaths)
Jebson-Taylor Hand Function Test.
• This easily administered test involves seven functional areas:
1) writing
2) card turning
3) picking up small objects
4) simulated feeding
5) stacking
6) picking up large, light objects
7) picking up large, heavy objects
• The subtests are timed for each limb. This test primarily measures gross
coordination, assessing prehension and manipulative skills with functional
tests. It does not test bilateral integration.
102
103
FINGERS: RANGE
OF MOTION AND
MANEUVERS
104
ASSESS FLEXION, EXTENSION, ABDUCTION, AND ADDUCTION
OF THE FINGERS
● Flexion - to test the Lumbricals and Finger flexor muscles
> “Make a tight fist with each hand, thumb across the knuckles.”
105
Range of Motion of the Wrist
106
107
Range of Motion of the Metacarpophalangeal Joint
0- 0- 0- 0- 0-
0- 0- 0- 0- 0-
0- 0- 0- 0-
0- 0- 0- 0-
0- 0- 0- 0-
0- 0- 0- 0-
0- 0- 0- 0-
0- 0- 0- 0-
108
● Extension - to test the finger extensor muscles.
> ask the patient to “Extend and spread the fingers
 Look for impaired hand movement in Arthritis, Trigger

finger, & Dupuytren’s contracture
Abduction & Adduction
ABDUCTION-to test the dorsal
interossei
ADDUCTION- to test the palmar
interossei
-inspect for impaired hand
movement in Arthritis, Trigger
finger and Dupuytren
contracture

THUMB
ASSESS THUMB FOR FLEXION, EXTENSION, ABDUCTION, ADDUCTION AND OPPOSITION

OTHER DEFORMITIES
OF HAND AND WRIST
2
OTHER DEFORMITIES OF HAND & WRIST
• Flexion Deformity of Distal Finger Joint— Mallet Finger
• Flexion Deformity of the PIP Joint— Boutonnie`re Deformity
• Flexion Deformity of the Thumb— Saluting Hand
• Extension Deformity of the PIP Joint— Swan Neck Deformity
• Snapping or Locking of Finger— Trigger Finger

MALLET
FINGER
• Flexion Deformity of DIP
• Cause: Rupture or avulsion
of the extensor tendon that
inserts on the distal phalanx
• The last 20° of active
extension is lost.

SALUTING
HAND
• Flexion Deformity of the Thumb
• Rupture of the Extensor pollicis
longus tendon
• The thumb is limply flexed in
the palm and cannot be
voluntarily extended

Boutonnie`r
e Deformity
•Flexion Deformity of the PIP Joint
• Cause: Rupture or avulsion of the
central band of the extensor tendon
•The deformity results from flexing
of the PIP joint and hyperextension
of the DIP joint.
•Finger is flexed at the PIP and lacks
voluntary extension
SWAN NECK
DEFORMITY
•Fixed extension of the PIP joint
• Cause: flexor tendons are
injured or sublux to the dorsum
of the joint, holding the joint in
extension.
• Common in RA and SLE

APE HAND
• Thumb is held in extension by its

inability to flex
• Occur in Syringomyelia,
Progressive muscular atrophy, or
Amyotrophic Lateral Sclerosis.

CLAWHAND
• Occurs from the predominant pull of the extensor

communis digitorum and the flexor digitorum
against weak or paralyzed interosseus and
lumbrical muscles.
• Caused by hyperextension of the MCP joints and
flexion of the interphalangeal articulations
• Paralysis may result from brachial plexus, ulnar
and median nerve injuries, syringomyelia, the
muscular atrophies, or acute poliomyelitis

BENEDICTION,
PREACHER’S, or
BISHOP’S HAND
• Ring and little fingers cannot be
extended
• Other digits move normally and may be
extended to produce the posture
• Occurs in:
• Ulnar nerve palsy
• Syringomyelia
• Extensor tendon rupture in RA
WRIST-DROP
• Pronated hand is held
horizontally, it drops from the
wrist
• Weak wrist extensors which are
unable to overcome gravity.
• Cause: Radial nerve injury of any
etiology

n d o f .
E s i o n …
Dis c u s

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Wrist and Hand

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Wrist and

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1.3 years old

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• Dislocation of the radiocarpal joint is the hallmark of Barton's

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• Fracture of distal 3rd of radius with dislocation of DRUJ

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•Flexor carpi ulnaris

They all originate from a common

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MOVEMENT OF THE LITTLE

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 Aching and numbness

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Froment’s “Paper” Sign.

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• Observe the hand in resting position and patterns of movement

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• OSTEOARTHRITIS (Degenerative Joint Disease)

• Usually hard and painless, they affect middle-

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Acute Rheumatoid Arthritis

Chronic Rheumatoid Arthritis

• Urate crystal deposits, often with surrounding inflammation, cause

 Median nerve compression

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• Swelling and/or tenderness

• Tenderness over the

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 Synovitis in the MCPs is painful with

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 Pain at the base of the thumb

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 Decreased sensation in the median nerve distribution characterizes

 Wrist pain and grip weakness - de Quervain’s Tenosynovitis

 Pain - de Quervain’s Tenosynovitis (inflammation of the Abductor Pollicis

 Look for impaired hand movement in Arthritis, Trigger

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• Thumb is held in extension by its

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• Occurs from the predominant pull of the extensor