FOREARM, WRIST, AND HAND
SELECTED MOVEMENTS
Active movements sometimes are referred to as physiological movements. If a pathological condition affects only one area of the hand or wrist, only that area needs to be assessed, provided the examiner is satisfied that the condition does not affect or has not affected the function of the other areas of the forearm, wrist, and hand. For example, if the patient has suffered a fall on the outstretched hand (FOOSH) injury to the wrist, the examiner spends most of the examination looking at the wrist. However, because positioning of the wrist can affect the function of the rest of the hand and forearm, the examiner must determine the functional effect of the injury on these other areas. Also, if the injury is chronic, adaptive changes may have occurred in adjacent joints.
The patient is asked to actively flex, extend, ulnarly deviate, and radially deviate the wrist. The patient next is asked to flex, extend, and ulnarly and radially deviate the joints of the digits. The most painful movements are done last. If active movement is pain free, overpressure can be added at the end of each movement. If active movement is painful, no overpressure should be added. The tests are most commonly assessed with the forearm in a pronated position, but it can be valuable for the examiner to test the patient’s active range of motion (ROM) with the forearm in neutral and in a supinated position. In some cases, the position of the elbow could affect the active movements of the wrist and hand.
INDICATIONS OF A POSITIVE TEST
Pronation and supination. Active pronation and supination of the forearm and wrist are approximately 85° to 90°, although this varies from individual to individual. It is more important to compare the movement with that of the normal side. Approximately 75° of supination or pronation occurs in the forearm articulations. The remaining 15° is the result of wrist action.
Wrist flexion and extension. Wrist flexion is 80° to 90°; wrist extension is 70° to 90°. The end feel of each movement is tissue stretch.
Radial and ulnar deviation. Radial and ulnar deviations of the wrist are 15° and 30° to 45°, respectively. The normal end feel of these movements is bone to bone.
Finger flexion. Flexion of the fingers occurs at the metacarpophalangeal joints (85° to 90°), followed by the proximal interphalangeal joints (100° to 115°) and the distal interphalangeal joints (80° to 90°).
Finger extension. Extension occurs at the metacarpophalangeal joints (30° to 45°), the proximal interphalangeal joints (0°), and the distal interphalangeal joints (20°). The end feel of finger flexion and extension is tissue stretch.
Finger abduction and adduction. Finger abduction occurs at the metacarpophalangeal joints (20° to 30°); the end feel is tissue stretch. Finger adduction (0°) occurs at the same joint.
Thumb flexion. Thumb flexion occurs at the carpometacarpal joint (45° to 50°), the metacarpophalangeal joint (50° to 55°), and the interphalangeal joint (80° to 90°). It is associated with medial rotation of the thumb as a result of the saddle shape of the carpometacarpal joint.
Thumb extension. Extension of the thumb occurs at the interphalangeal joint (0° to 5°); it is associated with lateral rotation. Flexion and extension take place in a plane parallel to the palm of the hand.
Thumb abduction and adduction. Thumb abduction is 60° to 70°; thumb adduction is 30°. These movements occur in a plane at right angles to the flexion-extension plane.
• Pathological conditions in structures other than the joint may restrict ROM (e.g., muscle spasm, tight ligaments/capsules). If the examiner suspects a problem with these structures, passive movement end feels will help differentiate the problem.
• Most functional activities of the hand require the fingers and thumb to open at least 5 cm (2 inches), and the fingers should be able to flex within 1 to 2 cm (0.4 to 0.8 inches) of the distal palmar crease.
• If the patient complains of pain on supination, the examiner can differentiate between the distal radioulnar joint and the radiocarpal joints by passively supinating the ulna on the radius with no stress on the radiocarpal joint. If this passive movement is painful, the problem is in the distal radioulnar joint, not the radiocarpal joints. The normal end feel of both movements is tissue stretch, although in thin patients, the end feel of pronation may be bone to bone.
• Wrist flexion decreases as the fingers are flexed, just as finger flexion decreases as the wrist flexes, and movements of flexion and extension are limited, usually by the antagonistic muscles and ligaments.
• The digits are medially deviated slightly in relation to the metacarpal bones. When the fingers are flexed, they should point toward the scaphoid tubercle. In addition, the metacarpals are at an angle to each other.
FANNING AND FOLDING OF THE HAND1 
The examiner holds the scaphoid and trapezium with the index and middle finger of one hand and the pisiform and hamate of the other hand while the capitate is held with the thumbs on the dorsum of the hand.
INDICATIONS OF A POSITIVE TEST
The examiner folds and fans the hand, feeling the movement while monitoring motion and feeling for crepitus and joint motion. Reproduction of symptoms also is assessed. Symptom reproduction or abnormal movement or shifting of joints is an indication of a positive test result.
SPECIAL TESTS FOR LIGAMENT, CAPSULE, AND JONT INSTABILITY2–5
Relevant Special Tests
Ligamentous instability test for the fingers
Thumb ulnar collateral ligament laxity or instability test
Lunotriquetral ballottement (Reagan’s) test
Definition
Stability within the hand and wrist are critical for optimal upper extremity function. Instability can occur at any of the joints of the forearm, wrist, or hand. Typically, the stability of a joint depends on the coordinated interaction between the passive elements of the region (i.e., bone, cartilage, and ligaments) and the active elements (i.e., muscle, tendon, and neuromuscular control). Instability occurs when injury or a pathological condition alters this balance.
Suspected Injury
Epidemiology and Demographics
Dobyns et al.4 estimated that 10% of all carpal injuries result in carpal instability. This number increases when distal radius fractures occur. Tang5 reported that 30% of patients with distal radius fractures also have carpal instability.
Ulnar collateral ligament injuries to the thumb occur nine times more frequently than radial collateral ligament injuries. Individuals active in sports such as skiing and mountain bike riding are prone to this injury.
Relevant History
If instability and laxity are the result of injury or trauma, no prior history of pathology needs to be present in the region. If the instability or laxity is the result of disease processes, the patient may have a past history of diseases that affect soft tissues. A prime example of this is rheumatoid arthritis, which significantly affects the laxity of the joints of the hand and wrist.
Relevant Signs and Symptoms
• Localized pain may occur over the injured tissue, especially when the individual is gripping, using the hand, or weight bearing on the hand.
• Generalized pain may be present.
• Swelling may or may not be present.
• Clicking or catching may be noted with functional use.
• The patient may complain of weakness in the hand and wrist.
Mechanism of Injury
The most common mechanism of injury is trauma, such as a fall onto the hand (FOOSH) or wrist. Injury also can occur whenever the ligaments are subjected to tensile forces that exceed their physiological capacities. Because the ligaments are damaged, passive stability is lost and active stability is needed. The muscles, tendons, and nerves of the wrist and forearm provide the active stability to the region. However, in the wrist and hand, most joints have no direct muscle or tendon attachment. Instead, the tendons of the muscle overlie the affected joint and have no direct control over the wrist motion or stability. As a result, instability is common after trauma and persists without the neuromuscular system contribution. Although the initial mechanism is different when ligament damage is the result of disease processes, the reason for the lack of stability in the joint is similar.
LIGAMENTOUS INSTABILITY TEST FOR THE FINGERS 
To assess the integrity of the collateral ligaments of the metacarpophalangeal and interphalangeal joints of the fingers.
The uninvolved hand is tested first. The examiner stabilizes the finger with one hand proximal to the joint to be tested. With the other hand, the examiner grasps the finger distal to the test joint and places the joint in the resting position. The examiner’s distal hand then is used to apply a varus or valgus stress to the joint (proximal or distal phalanx) to test the integrity of the collateral ligaments.
INDICATIONS OF A POSITIVE TEST
The results for the uninvolved hand are compared for laxity with those of the affected hand.
THUMB ULNAR COLLATERAL LIGAMENT LAXITY OR INSTABILITY TEST6,7 
The examiner stabilizes the patient’s hand with one hand and takes the patient’s thumb into extension with the other hand. While holding the thumb in extension, the examiner applies a valgus stress to the metacarpophalangeal joint of the thumb, stressing the ulnar collateral ligament and accessory collateral ligament.
INDICATIONS OF A POSITIVE TEST
Valgus movement greater than 30° to 35° indicates a complete tear of the ulnar collateral and accessory collateral ligaments. Laxity of less than 30° to 35° indicates a partial tear, which is still greater than would be seen on the unaffected side (normal laxity in extension is about 15°).
LUNOTRIQUETRAL BALLOTTEMENT (REAGAN’S) TEST8–10 
To assess the integrity and stability of the lunotriquetral ligament and lunotriquetral joint in the wrist.
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 stabilizes the triquetrum with a finger and the thumb of one hand and moves the lunate up and down (anteriorly and posteriorly) with the finger and thumb of the other hand.
INDICATIONS OF A POSITIVE TEST
Joint laxity, crepitus, or pain all are indicators of a positive test result for lunotriquetral instability.
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