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THE HAND & WRIST EXAMMatthew Silvis, MDDepartments of Family and Community Medicine & Orthopedics and RehabilitationPAFP Chesapeake Escape CME ConferenceJuly 28th, 2015
1
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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2
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
3
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
Am Fam Physician 2003; 68: 2167-76.
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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4
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
Am Fam Physician 2003; 68: 2167-76.
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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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5
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
Am Fam Physician 2004; 69: 1941-8.
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THE PALM OF THE HAND
Am Fam Physician 2004; 69: 1941-8.
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ANATOMY OF THE FINGER
Am Fam Physician 2006; 73: 810-6, 823.
Am Fam Physician 2001; 63: 1961-6.
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SIGNS OF TENDON INJURIES
Extensor tendon injury at DIP joint Mallet finger
Flexor digitorumprofundus tendon injury Jersey finger
Am Fam Physician 2004; 69: 1941-8.
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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 2004; 69: 1941-8.
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
Am Fam Physician 2004; 69: 1941-8.
Hand Clinic 2010; 26: 129-144.
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10
THE SHUCK TEST
Perilunate instability Wrist held in flexion Patient extends
his/her fingers while physician resists
+ pain
Am Fam Physician 2004; 69: 1941-8.
28
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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11
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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12
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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13
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
Am Fam Physician 2012; 85: 805-810.
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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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16
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
17
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.
50
STENAR LESION: NOTE THAT THE PROXIMALEND OF THE UCL DISPLACES OUT OF THEADDUCTOR APONEUROSIS
Am Fam Physician 2006; 73: 827-34, 839. 51
18
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?
53
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.
55
TYPES OF SCAPHOID FRACTURES
Hand Clinics 2010; 26 (1): 97-103.
56
DEDICATED SCAPHOID VIEWMRI IF NEEDED…
Am Fam Physician 2005; 72: 1753-8.
Sports Health 2009; 1 (6): 469-477.
57
20
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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21
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
61
JAMA 2000; 283: 3110-3117.
Median nerve directly beneath palmaris longus tendon at midpoint of wristmedial to flexor carpi radialis tendon.
62
HAND SYMPTOM DIAGRAM
A, classic B, probable C, unlikely
Am Fam Physician 2011; 83: 952-58.
63
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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)
64
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
65
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
23
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?
67
DISTAL RADIUS FRACTURE
FOOSH injury Swelling of wrist ? Gross deformity Limited ROM Point tenderness
distal radius Obtain x-rays
Miamihandcenter.com
68
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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