Wrist and Hand History and Physical Exam
History
Inspection
- be on the lookout for signs of systemic disease: clubbing
- psoriatic nail pits
- Dupuytren's contracture
- Abnormalities associated with rheumatoid arthritis:
- Boutonniere: PIP flexion, DIP hyperextension
- Swan-neck: PIP hyperextension, DIP flexion
- ulnar deviation at MCP joints
- swelling of MCP and PIP joints in RA, PIP and DIP joints in OA
- scars
- redness
- subluxation, (ie ulnar deviation in RA)
thenar atrophy with median nerve problems, hypothenar or interossei atrophy in ulnar nerve problems.
Dupetrene's contractures may be present in the palm
Palpation
bony landmarks:
- ulnar styloid
- radial styloid
- Lister's tubercule
- scaphoid bone in snuff box
joints:
- radiocarpal joint
- palpate joints using two fingers beside and two above
- hard like an almond: osteophytes of OA
- swollen like a grape: RA
- in OA, DIPs, PIPs, and thumb MCP joint tend to be involved
- in RA, PIPs and MCPs tend to be affected
soft tissue:
- extensor tendons
- extensor pollicus longus, extensor pollicus brevis, abductor pollicus longus tendons
- potential ganglion on dorsum due to synovial tissue outpouching from joint/tendon sheath
Range of Motion
- wrist flexion/extension
- radial/ulnar deviation
- supination (palms up) and pronation
- finger flexion/extension - each joint
- finger abduction (dorsal interossei) and adduction (palmar interossei)
- thumb flexion/extension/abduction/adduction/opposition
Special Tests
carpal tunnel syndrome tests:
- wasting of thenar eminence
- muscle strength of muscle innervated by median nerve, ie opponens pollicus or abductor pollicus brevis
- decreased sensation on palmar aspect of digits
- Tinel's sign at wrist
- Phalen's test: palms together, wrists flexed; positive if pain or paresthesias into hand