the hand wrist exam - pennsylvania academy of family ... s... · anatomy of the finger am fam...

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THE HAND & WRIST EXAMMatthew Silvis, MDDepartments of Family and Community Medicine & Orthopedics and RehabilitationPAFP Chesapeake Escape CME ConferenceJuly 28th, 2015

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DISCLOSURE

I have no financial or any other interest in any commercial product mentioned in this presentation. No conflict of interest exist.

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LEARNING OBJECTIVES

Perform a detailed hand examination. Perform a detailed wrist examination Describe the pertinent underlying anatomy of

common sports medicine conditions for both the hand and the wrist and their relation to findings on physical examination.

This is difficult material… the anatomy is detailed and the disorders are large in number and varied. This talk is meant to provide you with a general approach and is not all inclusive.

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OUTLINE

Inspection Palpation Range of Motion Sensation Strength Specific Tests Illustrative Cases

Primary survey Secondary survey

Some authors recommend a regional approach Radial, dorsal, ulnar,

palmar…

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FOCUSED HISTORY

Detailed history (identifies problem in 70% of cases) Patient should describe in their own words

“Act out event” Consider age of patient

FOOSH injury Greenstick fracture toddler Growth plate fracture adolescent Scaphoid fracture young adult Distal radius fracture (Colle’s fracture) in older adult with

osteoporosis

Based on physical examination, should be able to make a diagnosis or narrow the DDx dramatically Summation of anatomic locations where symptoms are

provoked by palpation and where signs are produced by manipulation

Imaging supportive 5

MAJOR EMERGENCIES

Dyvascular hand Acute severe

compression syndrome Open fractures Dislocations Traumatic

amputations

Denverhealth.org6

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OBSERVATION/INSPECTION: ACUTETRAUMA

Erythema, swelling, masses, skin lesions, muscle atrophy, contractures, scars, deformities

Acute Severe pain, swelling,

guarding may limit your exam!

Am Fam Physician 2001; 63: 1961-6.

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OBSERVATION/INSPECTION: HANDINFECTIONS


Acute paronychia

Felon

Herpetic Whitlow

Pyogenic flexor tenosynovitis

Even smallest puncture wound could indicate open fracture…

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OBSERVATION/INSPECTION: ARTHRITIS

Am Fam Physician 2012; 85 (1): 49-56.

1. Heberden nodes2. Bouchard nodes

PIP, MCP joint bogginess and swelling.

Am Fam Physician 2011; 84 (11): 1245-1252.

Osteoarthritis

Rheumatoid Arthritis

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OBSERVATION/INSPECTION: CHRONIC

Trigger fingerDupuytren’s Disease

Med.und.eduHealthtap.com

Am Fam Physician 2007; 76: 86-9, 90.

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THE POSITION OF FUNCTION

Safe splint position for hand

Hand is held as if holding the bowl of a wine glass

Wrist should be extended 25º and should allow alignment of the thumb with the forearm

MCP joint moderately flexed to 60º

IP joints slightly flexed PIP, 10º DIP, 5º

Thumb abducted away from the palm


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PALPATION

Mainstay of hand/wrist exam! 3 principles:

Exact point of local tenderness is the location of the pathology.

If one knows the exact location and underlying anatomic structure, one likely knows the diagnosis.

The diagnosis is arrived at by the summation of positive and negative physical exam findings.

Orthopedics is like real estate, it is all about location!

Hand Clin 2010; 26: 21-30.

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RANGE OF MOTION

Wrist: Flexion, 70º Extension, 70º Radial deviation, 20º Ulnar deviation, 40º

Forearm: Pronation, 80˚ Supination, 80˚

Faculty.washington.edu

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SENSATION: PERIPHERAL NERVES, UPPEREXTREMITY

NERVE MUSCLE AND FUNCTION

SENSORY AREA

Axillary Deltoid (shoulder abduction)

Lateral aspect arm

Musculocutaneous Biceps (elbow flexion) Lateral proximalforearm

Median Flexor pollicis longus(thumb flexion)

Tip of thumb, volaraspect

Ulnar First dorsalinterosseous(abduction)

Tip of little finger, volar aspect

Radial Extensor pollicislongus (thumb extension)

Dorsum thumb web space

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MOTOR EXAM

Median nerve Resisted thumb

abduction (palmar) Muscle belly palpated

Ulnar nerve Index finger abducted

against resistance 1st dorsal interosseous

muscle belly palpated

Radial nerve Thumb retropulsed

dorsally against resistance

EPL palpated

Sports Health 2009; 1 (6): 469-477.15

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STRENGTH

Mass/atrophy Consistency Tenderness Strength Testing

0/5: No muscle movement 1/5: Visible muscle

movement but no movement at joint

2/5: Movement at the joint but not against gravity

3/5: Movement against gravity but not added resistance

4/5: Movement against resistance, less than usual

5/5: NL strength

Photo-dictionary.com

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THE DORSUM OF THE HAND


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THE PALM OF THE HAND


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ANATOMY OF THE FINGER

Am Fam Physician 2006; 73: 810-6, 823.


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SIGNS OF TENDON INJURIES

Extensor tendon injury at DIP joint Mallet finger

Flexor digitorumprofundus tendon injury Jersey finger


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TRIGGER FINGER

Flexor tendons glide back and forth under 4 annular and 3 cruciform pulleys that keep the tendons from bowstringing The flexor tendon or first

annular pulley may become thickened and narrowed from chronic inflammation and irritation

Motion of tendon is limited and finger may snap or lock during flexion

Long and ring fingers Idiopathic or associated

with RA, DM NSAID’s, injection, surgical

releaseMethodistorthopedics.com

Elementalbw.comWebmd.com

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EXTENSOR COMPARTMENTS OF THE WRIST

I: APL, EPB

II: Extensor carpiradialis brevis and longus

III: Extensor pollicislongus

IV: Extensor digitorumand extensor indicis

V: Extensor digitiminimi

VI: Extensor carpiulnaris

www.aofoundation.org22

DE QUERVAIN’S TENOSYNOVITIS

Swelling/stenosis of the sheath that surrounds the abductor pollicuslongus (APL) and extensor pollicus brevis(EPB) tendons at the wrist

Pain, swelling, triggering of thumb

Repetitive use Finkelstein’s test Thumb spica splint,

NSAID’s, injection, surgical treatment

Orthopaedicsurgeon.com.sg

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DE QUERVAIN’S TENOSYNOVITIS, U/S FINDINGS…

Tendinosis S/P Injection

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THE BONES OF THE WRIST


Am Fam Physician 2005; 72: 1753-8. 25

HAND AND WRIST RADIOGRAPHS

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THE WATSON OR SCAPHOID SHIFT TEST

Press scaphoid tuberosity on palmar aspect while moving the wrist from ulnar to radial deviation

Painful click or pop Scaphoid instability Scapholunate

separation


Hand Clinic 2010; 26: 129-144.

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THE SHUCK TEST

Perilunate instability Wrist held in flexion Patient extends

his/her fingers while physician resists

+ pain


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CASE #1

16 y/o female soccer player Finger “jammed” after being struck with the ball + pain in 3rd digit Obvious deformity of PIP joint – appears to be

dislocated dorsally

How should this injury be treated? What about finger fractures?

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FINGER DISLOCATIONS

PIP joint is most commonly dislocated joint in the body

Dorsal >> volar Tenderness of volar

plate with obvious deformity

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FINGER DISLOCATIONS

Am Fam Physician 2006; 73: 827-34, 839.

If athlete is at event, can attempt reduction without radiography

If successful, buddy tape PIP joint in slight flexion

Reevaluate after athletic event at the office with radiography

If reduction is immediate, no anesthesia

If delayed > 1 hour, need digital block

Refer if large fracture fragment or if reduction fails

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FINGER FRACTURES

DIP joint Crushing injury Unless severe

angulation or displacement is present, fractures should be reduced and DIP joint splinted in full extension using stack or aluminum splint for 4-6 weeks and reevaluated

Littleastonoasis.com

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DETECTING MIDDLE PHALANX FRACTURES

Am Fam Physician 2006; 73: 827-34, 839.Am Fam Physician 2004; 69: 1941-8.

No RotationRotation; fingertips should

point towards scaphoid.

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MIDDLE PHALANX FRACTURES

Need proper alignment Difficult due to tension created by extensor/flexor

tendons Digital/hematoma block If reduction successful, splint PIP in extension

times 6 weeks Refer if: proximal phalanx, articular surface

fracture > 30%, reduction unsuccessful, rotation detected

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CASE #2

28 y/o male wrestling coach Presents 2 months after being struck with a

football – 2nd digit Unable to extend at the DIP joint This problem has persisted

What is the injured structure? Can this heal without surgery? What if he couldn’t flex at the DIP joint?

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MALLET FINGER

Extensor tendon injury at the DIP joint

Most common closed tendon injury of the fingers

Usually object strikes finger (ball)

Forceful flexion of an extended DIP joint

Extensor tendon stretched, partially torn, ruptured, or separated by avulsion fracture

Am Fam Physician 2006; 73: 810-6, 823.

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MALLET FINGER

Pain at DIP joint Inability to actively extend the joint

Flexion deformity

Isolate DIP to ensure no central slip injury Absence of full passive extension

may indicate bony or soft tissue entrapment

Bony avulsions in > 30% If no avulsion, splint in neutral or

slight hyperextension for 6 weeks Then splint at night only for

additional 6 weeks

Conservative treatment successful for up to 3 months (delayed)

Refer if: bony avulsions > 30% joint space or inability to achieve full passive extension


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JERSEY FINGER

Am Fam Physician 2006; 73; 810-6, 823.Am Fam Physician 2012; 85: 805-810.

Flexor digitorumprofundus tendon injury

Athlete catches finger on another player’s clothing Football, rugby

Forced extension of the DIP joint during active flexion

Ring finger is weakest (75% of cases)

Pain/swelling DIP joint Finger extended at rest Refer – needs seen

ASAP!!!38

CASE #3

14 y/o female basketball player Dominant 3rd digit forcefully flexed while

extended during a fall + pain and swelling dorsal aspect of middle

phalanx Unable to fully extend at PIP joint

What is the pertinent underlying anatomy and diagnosis?

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CENTRAL SLIP EXTENSOR TENDON INJURY

PIP joint is forcefully flexed while actively extended Basketball

Evaluate by holding PIP joint in 15-30˚ flexion If PIP injured, unable to

actively extend joint Passive possible Extensor tendon (central

slip) at PIP ruptures; lateral bands slip volarand flex PIP

Tenderness over dorsal aspect of middle phalanx

Treat as if mallet fingerAm Fam Physician 2006; 73: 810-6, 823. 40

UNTREATED CENTRAL SLIP EXTENSOR TENDONINJURY LEADS TO A BOUTONNIERE DEFORMITY

Sciencedirect.com

Orthoinfo.aaos.org

Intact lateral bands slip inferiorly.Flexion PIP with hypertension of DIP and MCP joints.

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CASE #4

22 y/o male boxer Missed punch Pain/swelling over

distal 5th metacarpal Loss of knuckle height

What is the diagnosis? How much angulationis tolerated?

worldsportedition.blog42

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BOXER’S FRACTURE

Fracture of the base of the 5th metacarpal bone often caused by missed punch during boxing

Most common metacarpal bone fracture

Distal fracture fragment displaced volarly because of interosseous muscles

Angulation at the metacarpal neck up to 40˚ can be tolerated but reduction should be attempted 2nd (10˚), 3rd (20˚), 4th (30˚)

If rotation present, refer Am Fam Physician 2006; 827-34, 839.

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BOXER’S FRACTURE REDUCTION

Apply dorsally directed pressure to volarlydisplaced MCP head

Volarly directed pressure to proximal fracture fragment

Proximal phalanx or PIP joint can act as lever arm

If reduction successful, splint in 70-90˚ flexion for 6 weeks in ulnar gutter splint/cast

Am Fam Physician 2006; 73: 827-34, 839.

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CASE #5

23 male baseball player Direct palmar impact

from swinging a baseball bat and striking the ball

Pain over the ulnar side of the palm

What is the pertinent underlying anatomy?

True/False: This bone fragment is typically removed for treatment.

Istockphoto.com

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HOOK OF HAMATE FRACTURE

Bony process Pulley for flexor tendons

during power grip Baseball, golf, tennis

Force transmission from bat, club, or racquet to the palm

Difficult to diagnose Hook sits one thumbnail

radial and distal to pisiform Carpal tunnel radiograph

May need advanced imaging Excision of fragment Immobilize then for 10-14

days RTP in 6-8 weeks

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CASE #6 26 y/o male Plays in a local football

league Upset and punched

another player’s mouth Small laceration over

dorsum of hand Now, pain, swelling

How should this injury be treated?

Who has a dirtier mouth: humans or animals? Am Fam Physician 2003; 68: 2167-76.

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FIGHT BITE

Clenched fist injury Injury with MCP in flexion,

laceration Injuries to extensor tendon

and/or joint capsule Human bites more virulent

than animal bites Polymicrobial (~5), anaerobes

Radiographs Wound should be explored,

irrigated, debrided No sutures

Splint in position of motion Antibiotics – inpatient vs

outpatient

Esquire.com48

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CASE #7

18 y/o female skier Fell onto ski pole Pain ulnar side of

thumb

What is the likely injured structure? What is a Stenarlesion?

123rf.com 49

SKIER’S THUMB

Disruption of the UCL cased by forced abduction of the MCP joint Partial or complete tear

with or without avulsion fracture

If left untreated, joint unstable leading to weak pinch grip

Diagnose 30º overall valgus laxity 15º difference between

sides Lack firm endpoint

Radiography (with stress views)

MRI or MSK U/S if neededAm Fam Physician 2006; 73: 827-34, 839.

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STENAR LESION: NOTE THAT THE PROXIMALEND OF THE UCL DISPLACES OUT OF THEADDUCTOR APONEUROSIS

Am Fam Physician 2006; 73: 827-34, 839. 51

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SKIER’S THUMB TREATMENT

J Bone Joint Surg Am 2012; 94: 2005-2012

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CASE #8

23 y/o female field hockey player Lifting weights at the gym and trips over a free

weight lying on the ground Falls onto outstretched hand (FOOSH) Pain in anatomic snuffbox

What is the anatomic snuffbox? What is the likely injured structure? Why doesn’t this injury heal well?

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SCAPHOID FRACTURE

Most commonly fractured carpal bone

FOOSH with primarily radial load

Radial sided wrist pain Tenderness of anatomic

snuffbox Between first and third

extensor compartments

Pain with axial loading of thumb Eorthopod.com

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Sports Health 2009; 1 (6): 469-477.

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TYPES OF SCAPHOID FRACTURES

Hand Clinics 2010; 26 (1): 97-103.

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DEDICATED SCAPHOID VIEWMRI IF NEEDED…


Sports Health 2009; 1 (6): 469-477.

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SCAPHOID FRACTURE MANAGEMENT

Complications are difficult to manage Blood supply enters

distal ½ of bone Proximal pole fractures

at high risk for avascular necrosis

Non-displaced middle 1/3 fractures Thumb spica splint/cast Compressive screw

fixation Referral to hand surgery

should be strongly considered!

Activemotionphysio.ca58

SO WHAT’S THE DIFFERENCE: WRISTSPLINT VERSUS THUMB SPICA SPLINT

Myorthomd.comBreg.com

Wrist splint

Thumb spicasplint

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CASE #9

42 y/o female Extensive typing at

work Tingling in digits 1-3 Discomfort radiates to

forearm

What is the function of the median nerve? What is the carpal tunnel?

Pfflaw.com

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CARPAL TUNNEL SYNDROME

Common 2.7-5.8% population Bilateral in ~50% Especially overuse-type injuries caused by

repetitive motion Median nerve distribution Pain, parethesias May radiate proximally to forearm and even

arm/shoulder +/- loss of grip strength

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JAMA 2000; 283: 3110-3117.

Median nerve directly beneath palmaris longus tendon at midpoint of wristmedial to flexor carpi radialis tendon.

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HAND SYMPTOM DIAGRAM

A, classic B, probable C, unlikely


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DIAGNOSIS AND TREATMENT

Tests: Flick sign 2 point discrimination test

2 points < 6 mm apart (caliper)

Tinel sign Phalen maneuver Nocturnal parethesias Thenar atrophy

EMG/NCS – not usually indicated if high probability based on history and exam

Mild – neutral wrist splint, steroids, ergonomics Moderate/severe – surgery (open or endoscopic)

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CASE #10

22 y/o female school teacher

Cyst like structure over dorsum of wrist

Soft, painful with palpation

Worsens with chalkboard writing

What is a ganglion cyst and what does it arise from?

Psdgraphics.com

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GANGLION CYST

Arises from the capsule of the joint or tendon synovial sheath Thick, clear, mucinous

material One-way valve Dorsum of wrist, volar radial

aspect of wrist, base of finger (A1 pulley of flexor tendon sheath)

15-40 years of age Smooth, round, or multi-

lobulated Mildly tender with

palpation Can try aspiration Surgical excision is

definitive 66

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CASE #11

19 y/o rugby player Fell onto outstretched hand (FOOSH) Pain and swelling in distal forearm Point tenderness distal radius

What is the likely diagnosis and treatment?

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DISTAL RADIUS FRACTURE

FOOSH injury Swelling of wrist ? Gross deformity Limited ROM Point tenderness

distal radius Obtain x-rays

Miamihandcenter.com

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DISTAL RADIUS FRACTURE MANAGEMENT

If displaced, closed reduction Hematoma block vs

sedation X-ray after reduction

If stable and aligned, cast If unstable or not able to

align, operative intervention

Healing takes 6-8 weeks Early finger ROM and

swelling control when subacute

Upon healing of fracture, wrist and forearm ROM, progressive strengthening prior to RTP

Sports Health 2009; 1(6): 469-477.

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CASE #12

9 y/o female gymnast Progressive bilateral wrist pain made worse with

wrist in extension such as when tumbling, vaulting, and back walkovers

Normal ROM with swelling of the distal radius, right > left

Tenderness over the dorsal-radial growth plate No snuff box tenderness

What is the likely diagnosis, how is this condition treated, and are the x-ray findings reversible? 70

DISTAL RADIAL EPIPHYSITIS

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DISTAL RADIAL EPIPHYSITIS

Most common in male and female gymnasts “Gymnast’s wrist”

Radial physes appear at age 12-18 months and fuse by 15-18 years

Radiographic findings Sclerosis (metaphyseal) Widening (radial/volar)

Treatment Cessation of activities that

require weightbearing, use of dowel grips, or excessive traction on the extended wrist

Radiographic findings reverse in most…

Permanent changes have been reported Shortening of the radius Madelung’s deformity

Healing Negative radiographs

4 weeks Cast – mainstay of treatment “Just do some handstands and

see how it feels” Severe involvement

> 6 months Slowest of all physeal injuries to

heal

www.davidlnelson.md/images.

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THANK YOU! ANY QUESTIONS?

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the hand wrist exam - pennsylvania academy of family ... s... · anatomy of the finger am fam...

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