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INTRODUCTION

• Wash hands

• Introduce yourself  saya… medical student, nama anda siapa?

• Explain what you would like to examine saya mau periksa tangan,

melihat, palpasi, sama ngeliat pergerakan2nya• Gain consent boleh nggak?

• sk about pain sblm saya mulai pemeriksaannya ada yang pain nggk?

• Expose patients hands, wrists and elbows

• !osition " hands on lap, on pillow with palms down

ELBOWLook #dr depan, samping, belakang$!osisi % arm ekstensi, palm supinasi  bandingin kanan kiri&iat 'algus angle  buat cek cubitus 'algus  karena malunion lateral

condyle fracture&iat cubitus 'arus  maluinon supracondyle fracture

&iat swelling, scar

&iat biceps tendon  liat ada ruptur?  bakal retraksi proximalFeel(ony palpation  liat crepitus, pain, swelling, temperature)ek %

*+ adial head #osteoarthritis$2+ -lecranon fossa.+ /lnar border

. dibawah bakal bentuk isosceles triangle kalo elbow 0ex 1 dera3atdan bakal ngebentuk garis lurus kalo elbow full extension

4+ -lecranon process5+ &ateral epicondyle

6+ medial epicondyle

7oft tissue palpation

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*+ 8edial aspect)ek ulnar ner'e, wrist 0exor pronator group, supracondylar lymphnodes #buat liat infeksi$

2+ !osterior aspect)ek olecranon bursa, triceps muscle

.+ &ateral aspect)ek wrist extensor  brachioradialis, extensor carpi radialis longus,extensor carpi radialis bre'is

4+ nterior aspect)ubital fossa, biceps tendon #ga ke palpable pd tendon rupture$,brachial arteri, median ner'e

Move

•  9angan kaya mau terbang ini sama a3a buat cek extension #normal :minus * dera3at$

• )ek 0exion tangan suruh kaya nun3ukin otot #normal *.:*4$

• )ek pronasi supinasi  tangan nempel badan di samping, depan

diangkat kaya lg main game, 3empol suruh angkat kaya good  3empolke lateral di buka #supinasi$ ke dalem buat pronasi

Special test

*+ &igamentous stability

cek kalo ada gap2+ 9ennis elbow test

Elbow ExaminationThe elbow exam is a simple examination that can be administered as part of the physical examto help guide healthcare providers diagnosis and management of acute elbow fractures. The

elbow examination is performed when an elbow fracture, most commonly caused by trauma, issuspected as the source of pain and dysfunction.

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Subject steps1. Begin by washing your hands. Explain the procedure to the patient and gain informed

consent to continue.

2. Begin with observation of the patient. Inspect the front to chec the carrying angle,from the side to chec for a fixed flexion deformity, and from behind and on the insideto chec for scars, swellings, rashes, rheumatoid nodules and psoriatic pla!ues.

 Inspect the front Inspect the side

http%;;www+osceskills+com;resources;Inspect:behind:and:on:the:inside:for:scars:swellings:rashes:rheumatoid:nodules:and:psoriatic:pla<ues+3pgInspect behind and on the inside

". #eel the elbow, assessing the $oint temperature relative to the rest of the arm. %alpatethe olecranon process as well as the lateral and medial epicondyles for tenderness.

 &ssess the $oint temperature

http%;;www+osceskills+com;resources;!alpate:the:olecranon:process:as:well:as:the:lateral:and:medial:epicondyles:for:tenderness+3pg%alpate the olecranon process

'. The movements at the elbow $oint are all fairly easy to describe and assess. These are

flexion, extension, pronation and supination. (nce these have been assessed activelythey should be checed passively checing for crepitus.

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 #lexion $oint movement Extension $oint movement

%ronation $oint movement )upination $oint movement*. #inally you should chec for tennis elbow and golfer+s elbow.

Tennis elbow localises pain over the lateral epicondyle, particularly on active extensionof the wrist with the elbow bent. olfer+s elbow pain localises over the medialepicondyle and is made worse by flexing the wrist. -hec each of these individually toeliminate them.

 -hec for tennis elbow -hec for golfers elbow

. (n completion, than the patient for their time and wash your hands.

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HAND & WRISTInspeksi=igits, hand, wirst, palmar surfaceDos!"

7cars hbs oprasi? >bs trauma?=eformity : (ouchards nodes (PIP  proximal interphalang joint) ,>eberdens nodes (DIP)  tanda -;

7kin changes=orsal 8uscle Wasting dorsal interossei  but nge nge abduct index,middle, ring @ngers dan untuk 0exion pd knuckle 3oint dan eks

Aails " pitting #small depressions dr nail$ B onycholysis #detachment naildr nail bed$  !soriasis7wan neck deformity#=I! hiper0exi, !I! hiperextensi$  pd , congenital#ehlers:=anlos syndrome$

C:thumb wrist is shifted towards the thumb dan @ngers incline towards

the little @nger(outonniDres =eformity in3ury dr tendon pd @nger yg ngebuat @nger gabs fully straighthening

>bs itu suruh balik tangannya#al"7cars " carpal tunnel release surgery7welling=eformity : dupuytrens contracture

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 9henar; >ypothenar : wasting " carpal tunnel syndrome

Elbows " psoriatic pla<ues or rheumatoid nodules

#alpation#al"

 9henar; >ypothenar (ulk 9emperature : wrist B 8)! 3oint lines 9enderness!almar thickeningadial pulsesDos!"8)! s<ueee " often tender in RA / other inammatory arthropathies7ensation% #suruh tutup mata$ FAA FII▪ 8edian ner'e : thenar eminence  supinasi  ini ter aect di carpal

tunnel syndrome▪ /lnar ner'e : hypothenar eminence  supinasi

▪ adial ner'e : rst dorsal !e" space  pronasi

!alpate all 3oints% #pronasi$ #sambil liat muka pasien ada sakit atau engga$▪ Wrist▪ 8)! #metacarpophalangeal$  setiap 3oint dr wrist smpe ke u3ung 3ari  

liat ada swelling, 0uctuance;tenderness  hrs urut▪ !I!▪ =I!  liat mallet @nger  kalo ga dibener2in bs 3d swan neck

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▪  9ulang scaphoid  palpasi anatomical snuH:box  liat ada fraktur;tenderness nggk  suruh esktensi ibu 3ari

▪ 7oft tissue

: 9unnel * tendon dr abductor pollicis longus dan tendon drextensor pollicis bre'is

: 9unnel 2  tendon dr extensor carpi radialis longus dan extensor

carpi radialis bre'is: 9unnel .  tendon dr extensor pollicis longus: 9unnel 4  tendon dr extensor digitorum communis dan extensor

indicis: 9unnel 5  tendon dr extensor digiti minimi  index sm small @nger

suruh gerak2in pd saat yg lainnya 0exi: 9unnel 6  tendon dr extensor carpi ulnaris  wrist disuruh extend

MoveRotational "alali$n"ent7uruh 0eksi dr 4 3ari ke palm  liat hrs sesuai alignment #rata$Ran$e o% "otion

acti'eWrist extension " #prayer$   dera3atWrist 0exion " #re%erse prayer$   1 dera3at

passi'e #wrist$0exion;extension  tangan kiri wrist, tangan kanan pegang 3ari2  feeluntuk crepitusacti'e• strong  Jinger 0exion : #ma&e a st$  kalo susah brrti ada 3oint,

tendon, atau neurological disease• Jinger extension " #open your st ' splay (mele"ar) your ngers$  

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• cti'e Wrist ; Jinger Extension radial ner'e ),)K  suruh adduksisemua 3ari, tangan kita neken dr atas  3g ulnar de'iation dan radialde'iation

• Jinger abduction : index nger   ulnar ner'e )K,9*  lg abduction, kitaksh tahanan buat nge adduksiin

•  9humb abduction " #dont let me push your thum" into your palm$ (dlm&eadaan supinasi)  median ner%e *+ ,-

•  9humb 0exion : extension

F!nction

• !ower grip suruh nge s<ueee 3ari kita

• !incer Grip suruh nge s<ueee telun3uk pemeriksa u3ungnya a3a kayapen3epit

• !ick up small ob3ect " small coin &alo defect pd dexterity (aected "y 

 joint ' ner%e pathology)Special test

: &ong @nger 0exor test  dlm posisi pronasi  mis+ 8au periksa 3empol pegang yg 4 nya  3ari yg mau di periksa suruh gerakin kalo bsgerak normal

: (unnel:&ittler test  e'aluasi intrinsic muscles of the hand

: etinacular test  buat cek retinacular ligament

: Jinkelstein test  test stenosing tenosyno'itis dr tendon pd tunnel *L  sakit di snuH box

: !erform 9inels test " tap o'er carpal tunnel to elicit tingling " suggests

median ner%e compression: !halens test  buat cek carpal tunnel

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: llens test  cek patency dr collateral radial arteri dan ulnar arteri

TO COM#LETE THE EAM exam 9hank !atientWash >ands7ummarise Jindings

Hand & Wrist ExaminationThe hands are !uite difficult to examine as there are a number of signs which can be detected

from them. Try and remember each of these and also some of the causes behind the signs.1. &s always, wash your hands, explain the procedure to the patient and gain informedconsent.

2. #irstly place the patient+s hands on a pillow in between you and them, ensuring thepatient is comfortable.

Inspection preparation

". /ave a loo at the hands. In particular loo for swellings, deformities, muscle wasting,scars 0 particularly carpal tunnel release scars, sin changes, rashes, nail pitting or

onycholysis, nailfold vasculitis, palmar erythema. If there are $oint swellings note which $oints are involved and whether the changes are symmetrical or not.

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Inspect the hands

'. ou need to feel the hands. This should loo as smooth as possible so try and develop

your own techni!ue. & good one is to start proximally and wor towards the fingers. )o,start by feeling the radial pulses and the wrist $oints with the two thumbs on theextensor surface and the index fingers on the flexor surface. Then feel the muscle bulin the thenar and hypothenar eminences. In the palms, feel for any tendon thiceningand assess the sensation over the relevant areas supplied by the radial, ulnar andmedian nerves. &s with all other $oints, you should assess the temperature over the

 $oint areas and compare these with the temperature of the forearm. ext you shoulds!uee3e over the row of metacarpophalangeal $oints whilst watching the patient+s facefor any discomfort. ou should then move onto any 4-% $oints which are noticeablyswollen. %alpate these bimanually with your two thumbs on the dorsum and two indexfingers on the palm. 4ove onto the interphalangeal $oints and again palpate any which

are swollen. This palpation is done with one of the thumbs on the top and the other onone of the sides. The index fingers go on the vacant sides of the $oint.

#eel for temperature -arpals inspection

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Thenar inspection 4-% inspection

I% inspection

*. &t this point you should also loo at the underside of the elbows to chec for anypsoriatic pla!ues as these could suggect the presence of psoriatic arthritis and for anyrheumatoid nodules.

-hec for psoriatic pla!ues

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. The movements which should be assessed are wrist flexion and extension, fingerextension and flexion as well as abduction. ou should also test thumb abduction andopposition.

5rist flexion examination 5rist extension

examination

#inger flexion examination #inger extension examination

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  #inger abduction examination #inger abductionexamination 2

#inger opposition examination

6. (ne special test which you may lie to employ is %halen+s test. #orced flexion of the

 wrist, either against the other hand or by the examiner for 7 seconds will recreate thesymptoms of carpal tunnel syndrome. #roment+s test may also be performed to chec8lnar nerve function by asing the patient to hold a piece of paper between their thumband index finger 9hence checing adductor pollicis:. In a patient with 8lnar nerve palsythe interphalangeal $oint of the thumb will flex to compensate.

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%halen;s test

<. #inally you should perform a functional assessment of the patient. This involvesforming a power grip around your middle and index fingers, a pincer grip against your

index finger and asing your patient to pic up a small ob$ect such as a coin.

%ower grip assessment %incer grip assessment

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%ic=up assessment

>. Than the patient and wash your hands again.