History and Physical Examination
Craig M. Rodner
Christian A. Merrill
The aim of this chapter is to provide a systematic guide and template on which to perform a history and physical (H&P) examination in the setting of hand and wrist trauma. For all hand and wrist injuries, obtaining a thorough H&P is essential to establishing the correct diagnosis and making the appropriate treatment decision.
The mechanism of injury can provide insightful knowledge about the type of injury sustained in a hand or wrist trauma patient. It is important to assess whether the injury is blunt or penetrating in nature and whether or not this is high-energy versus a low-energy type of injury. This can provide context to the type and extent of injury sustained and various other structures that may be damaged in the acute trauma patient. The chief complaint, whether it be acute or more chronic in nature or potentially a sequela from a previously sustained trauma, should be investigated. The pain must be carefully examined for location, onset, duration, intensity, character, frequency, aggravating and relieving factors, night or rest pain, and radiating symptoms. Additionally, any associated symptoms such as catching, clicking, locking, weakness, numbness, or temperature sensitivities should be addressed. For both acute and chronic pathologies, the history of prior and current treatments should be examined. Any motor or sensory deficits should be inquired about.
Additionally, the patient’s handedness, occupation, and current work status should be ascertained. This information can add valuable insight into how this injury can affect the patient’s life and livelihood. With regard to past medical history and past surgical history, any history related to the afflicted extremity should be obtained; furthermore, any conditions that may increase the risk for infection, wound healing capacity, or vascular conditions should be documented. Social history should include any smoking, alcohol, or illicit drug use. Allergies and vaccination status, in particular tetanus updates, should be inquired about as well.
When performing the physical examination (PE), it is always important to remove all jewelry, clothing, bandages, splints, or other impedances such that the entire extremity could be examined. It is important to take a systematic approach to examining the fingers, hand, and wrist. The contralateral limb can always provide a reference for examination and can be examined first. It is often best to have the patient demonstrate the site of maximum pain by pointing with one finger and then approach this site last during examination.
Type—laceration, crush, inoculation, penetrating, avulsion, necrotic, caustic, burn
Shape—linear, stellate, complex, poke-hole, injection
Location—volar, dorsum, zone of injury (Figure 1.1)
What is exposed? Subcutaneous tissue, fat, muscle, tendon, bone, nerves, vessels
Swelling—diffuse versus localized
Natural resting position of hand—gentle flexion at the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints
Natural resting position of wrist—slight extension and ulnar deviation
Coronal, sagittal, rotational deformities notable to contralateral
Skin—color changes, hair loss, scar, wounds/sinus tracts
Hand—thenar, hypothenar, interosseous musculature
Forearm—flexor and extensor compartments
Palpation—assess tenderness, defects, step-offs, fluctuance, wounds
Nail—eponychium, paronychium, nail plate, and nail bed (Figure 1.3)
Digit—pulp, flexor tendon sheath, flexor tendon pulleys
Distal radius—radial styloid, Lister tubercle
Distal radioulnar joint (DRUJ)
Distal ulna—ulna head, ulnar styloid
Triangular fibrocartilage complex
Carpal bones—scaphoid (proximal pole and waist), lunate, trapezium, trapezoid, capitate, hamate
Carpometacarpal joints—thumb, index, middle, ring, small finger
Extensor compartments: (1) abductor pollicis longus (APL) and extensor pollicis brevis (EPB); (2) extensor carpi radialis brevis (ECRB) and longus (ECRL); (3) extensor pollicis longus (EPL); (4) extensor digitorum communis (EDC) and extensor indicis proprius (EIP); (5) extensor digiti minimi (EDM); (6) extensor carpi ulnaris (ECU)
Anatomic snuff box—between first and second extensor compartment
Carpal bones—scaphoid (tuberosity), trapezial ridge, pisiform, hook of hamate
Tendons—flexor carpi radialis (FCR), palmaris longus, flexor carpi ulnaris (FCU)
Neurovascular—radial and ulnar artery; median and ulnar nerve
Mass—tenderness, consistency, mobility, compressibility, transillumination, pulsatileness, sinus tract
Probing—explore wound with cotton tip applicator
Range of motion —assess both passive and active; assess smoothness of motion, abnormal movement, lack of movement, rotational deformity, scissoring (Table 1.1)
Passive tenodesis—fingers will flex with wrist passively extended and extend with passive flexion of the wrist (assess for tendon laceration) (Figure 1.5)
Lack of tenodesis—disruption of tendon or musculotendinous junction
Hand—make full fist, open completely
All fingertips should touch palm, fingertips point toward scaphoid tubercle (assess rotational deformities)
Wrist—move in all planes of motion
Muscular examination (Table 1.2)
FCR—make a fist and flex wrist, ulnar deviation of the wrist is indicative of weak or incompetent FCR. Strength against resistance in wrist flexion and radial deviation.
FCU—make a fist and flex wrist, radial deviation of the wrist is indicative of weak or incompetent FCU. Strength against resistance in wrist flexion and ulnar deviation.
Flexor digitorum superficialis (FDS)—flex PIP joint of each individual digit while all other digits’ MCP joint is stabilized in extension (Figure 1.6)
Prevents flexor digitorum profundus (FDP) from flexing because of quadriga effect because FDP tendons are connected to a single unit compared to FDS
FDP—flex DIP joint of each individual digit while PIP joint is stabilized in extension (Figure 1.7)
Flexor pollicis longus—flex interphalangeal (IP) joint of thumb while stabilizing thumb at proximal phalanx
APL—hand supinated on table, radially abduct thumb in plane of hand
EPB—extend proximal phalanx of thumb while IP joint of thumb flexed
EPL—extend IP joint of thumb with proximal phalanx stabilized; hand pronated on table, lift thumb off table
EDC—extend fingers at MCP joint with wrist stabilized in extension
Sagittal band incompetence—able to maintain MCP extension but cannot obtain actively
EIP—extend index finger with other fingers flexed and wrist in extension
EDM—extend small finger with all other fingers flexed and wrist in extension
ECRL and ECRB—make a fist and extend wrist, ulnar deviation of the wrist is indicative of weak or incompetent ECRL and/or ECRB. Strength against resistance in wrist extension and radial deviation.
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