Clinical examination of the wrist, thumb and hand

Clinical examination of the wrist, thumb and hand

Chapter contents

Referred pain

When a patient refers to the wrist as the site of symptoms, an area is indicated in which there are many structures that could be responsible. The region that patients call the wrist contains:

• The distal radioulnar joint

• The wrist joint

• The tendons that control the wrist

• The trapezium–first metacarpal joint

• The tendons that control the thumb

• The tendons that control the fingers

• The intrinsic muscles of the hand.

When a patient feels pain proximal to the distal radioulnar joint, this is usually described as being in the forearm. The same applies distally, where pain is described as being in the fingers.

Pain is usually the result of a local lesion, although more proximal causes, such as cervical, shoulder girdle and shoulder disorders, as well as problems at the elbow, may refer pain to the distal part of the upper limb. However, in a lesion in the distal part of the limb, the patient is able to point accurately to the exact site of the lesion and it is only when the clinical examination of the wrist and hand is negative that the lesion should be sought more proximally.

Paraesthesia, being a ‘nerve symptom’, may result either from lesions higher up in the segment (e. g. cervical spine or thoracic outlet) or from local lesions (e. g. ulnar nerve problem or carpal tunnel syndrome).

History

The history is seldom distinctive and therefore examination must be relied on for diagnosis. However, some questions are important.

• What is the problem? The patient describes the symptoms that are experienced in the wrist, thumb, hand or fingers. They are variable and may include pain, paraesthesia, numbness and weakness.

• How did it start? Was there an injury? Especially when a capsular pattern is found during the examination, the possibility of a fracture must be considered.

• Or did it start after particular exertion? Most ligamentous, muscular or tendinous lesions result from overuse. The symptoms may have started spontaneously, as usually happens in arthrotic or arthritic disorders.

• How has the problem developed? Because of the distal localization of the lesion, its evolution can only be judged in terms of the intensity of the symptoms, or by their appearance or disappearance, but not by reference of the symptoms.

Inspection

The typical articular deformities of arthrotic or arthritic changes in the joints are well known.

Local swelling may be found. In dorsal subluxation of a carpal bone, the bony projection is visible when the wrist is held in flexion. A cyst on the dorsal aspect may mimic such a subluxation. The same applies to mal-united fractures, where bony outcrops may be visible on inspection. Palpation or disappearance of a fluid collection after puncture will help to reveal the difference.

Another important aspect is generalized swelling. Swelling coming on quite soon after a trauma – for example, a fall – is highly suggestive of fracture of a carpal bone. Spontaneous swelling occurs in rheumatoid arthritis and is quite often bilateral. In long-standing rheumatoid arthritis, multiple large ganglia may also occur.

In arthrosis at the trapezium–first metacarpal joint, the thumb is often visibly fixed in adduction; osteophytes can be seen and felt.

There may be changes in the colour of the hands, which may suggest a circulatory disorder – for example, Raynaud’s syndrome, or a cervical rib pressing on the subclavian artery or vein.

Functional examination

Many different structures – inert and contractile – lie close together and have to be examined. It should be clear that by passive testing, which is meant to examine the inert structures, either stretching or pinching may elicit symptoms. In some instances, painful movement of a contractile structure is provoked – for example, of a tendon within its sheath.

The wrist, thumb and hand are examined using 21 tests (Box 20.1).

Box 20.1 Tests for the wrist, thumb and hand

The distal radioulnar joint

• 2 passive movements

• 4 passive movements

• 4 resisted movements

• 1 passive movement

• 4 resisted movements

• 6 resisted movements of the fingers

The distal radioulnar joint

The two movements described below test the integrity of the distal radioulnar joint. Painful supination is also a localizing sign in tendinitis of the extensor carpi ulnaris in the groove at the distal part of the ulna. The normal end-feel of both movements is capsular (elastic).

Passive pronation

The patient holds the elbow in 90° flexion. The examiner grasps the patient’s forearm just proximally to the wrist with both hands. The heel of the contralateral hand is placed on the palmar aspect of the ulna, the fingers of the other hand at the dorsal aspect of the radius. Pronation is performed by a simultaneous movement of both hands (Fig. 20.1a).

Fig 20.1 Passive pronation (a) and supination (b).

Passive supination

The examiner changes hand position and puts the fingers of the contralateral hand on to the palmar aspect of the radius and the heel of the other hand on the dorsal aspect of the ulna. Supination is again performed by a movement of both hands (Fig. 20.1b).

The wrist

Passive movements (Fig. 20.2)

The normal end-feel of flexion and extension is capsular (elastic). If these movements are positive, the examiner must be able to tell whether the condition is of the capsular or the non-capsular type (see Ch. 23).

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Tags: A System of Orthopaedic Medicine

Jun 5, 2016 | Posted by admin in ORTHOPEDIC | Comments Off

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