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Wrist and Hand Assessment Scan Exam Elbow Flexion, Extension Pronation, Supination Fingers Full fist, Half fist Palmar Surface atrophy- thenar (median n), hypothenar (ulnar n) Dorsal Surface knuckles- 3rd more prominent or all in line? muscle wasting shape of nails (clubbed, spoon, pitting, psoriasis) swelling (ganglion cyst) Heberden’s nodes (OA of DIP)- Bouchard’s nodes (OA of PIP) finger/hand deformities (swan neck, boutonniere, mallet/dropped, ulnar claw, median n palsy, trigger finger, dupuytren’s contracture General count fingers, size of hands, hand in resting position, atrophy Nerve Root Dermatome Myotome C4 clavicle ring shrug C5 lateral deltoids shoulder abduction biceps C6 thumb side elbow flex/wrist ext brachioradialis C7 middle finger elbow ext/wrist flex triceps C8 pinkie finger flex (claw) T1 medial elbow finger abd/add Grading ↓ or normal or ↑ 5/5 Active Passive Resisted radial deviation ulnar deviation 30-40° Grade 5/5 wrist flexion 80-90° w over pressure Observations bumps, bruises scars, redness rash, psoriasis moles, skin tags swelling, trauma Neurological * test bilaterally Movement Testing * painful last * passive w overpressure Reflex Reflex Response: 0=absent 1+=diminished 2+=normal 3+=brisk 4+=non sustained clonus, very brisk, clonus (rhythmic movement in response to reflex) 5+=sustained clonus * map out peripheral * sharp dull 2+ normal 15° bone-bone wrist extension tissue stretch finger Flexion finger Extension finger abduction thumb flexion thumb extension 85-105° abnormal end feels: -sudden/hard (mm spasm/guard) -capsular (soft- edema, hardfrozen) -boney (osteophytes) -empty (pain limits- bursitis) -springy block (meniscal) Opposition Thumb Adduction 70-90° 20-45° 20-30° 45-90° 0-5° 5th finger tip tissue approx 30° Wrist and Hand Assessment Palpation Bony * location * size/shape * tone/texture * temperature * edema * trigger points radial/ulnar styloid, tubercle of radius (listers tubercle)- in line with lunate carpal bones (scaphoid, lunate, triquetrium, pisiform, trapezium, trapezoid, capitate, hamate) hook of hamate -tunnel of guyon (passage for ulnar nerve) 1st MT- game keepers thumb 5th MT- bar room fx Soft Tissue zone 1: radial styloid tunnel 1: EPB, AbPL - site of De Quervain’s disease zone 2: at lister’s tubercle tunnel 2: ECRL/B tunnel 3: EPL - commonly ruptured with RA tunnel 4: ext digitorum, ext indicis (ganglion cysts) tunnel 5: ext. digiti minimi tendon tunnel 6: ext. carpi ulnaris tendon Wrist: zone 3: ulnar styloid zone 4:! pisiform & palmar aspect, FCU, tunnel of guyon, ulnar artery zone 5: !palmaris longus, carpal tunnel Special Tests Hand: zone 1: thenar emience zone 2: hypothenar eminence zone 3: palmar aspect- aponeurosis, finger flexor tendons zone 4: dorsum of hand- ext. tendons zone 5: phalanges Ligament Instability Tests 1. DRUJ Ballotement Test- instability of DRUJ 2. Piano Key Test- instability DRUJ 3. Thumb UCL Laxity Test- ulnar collateral ligament of the thumb Muscle, Tendon, Joint Path 1. Murphy’s Sign- lunate dislocation 2. Anatomical Snuff box compression Test- fx of scapoid 3. Finkelstein’s Test- De Quervain’s (stretch) 4. Brunelli’s Test- De Quervain’s (contract) 5. Bracelet Test- RA Neurological Tests 1. Tinel’s at the wrist- integrity of median nerve 2. Phalen’s/Reverse Phalen’s Test- integrity of median nerve 3. Carpal Compression Test- integrity of median nerve 4. Wringing Test- non specific test to localize wrist pain 5. Froment’s Sign Test- ulnar nerve 6. Pinch Grip Test- injury of anterior interosseous nerve (branch of median nerve) Vascular Test 1. Allen’s Test- tests blood flow through radial/ulnar arteries Condition Description Bennett’s Fx base of thumb Game Keepers thumb ulnar collateral ligament instability Bar Room fx 5th MT Colles fx fx of distal radius & dorsal displacement with or without ulnar fx CTS compression of median nerve Kienbocks lunate dislocation- avascular necrosis