Procedure 1 Examination of the Hand and Wrist

See Video 1: Clinical Examination of the Hand and Wrist

Figures 1-42 and 1-43 are from Chung KC, Yang L, McGillicuddy JE (eds). Practical Management of Pediatric and Adult Brachial Plexus Palsies. Philadelphia: Elsevier; 2011.

Man depends on his hands for work, recreation, and expression. The hand not only reflects emotional and physical character but also is a mirror of underlying systemic disease. An understanding of the basic functional anatomy of the hand is essential for examination, accurate diagnosis, and successful treatment of disorders of the hand. Standard terminology should be used when describing the anatomy and motion of the hand and wrist. This avoids confusion and compromised patient care when the pathology is described to colleagues.

The human hand consists of a broad palm with five digits, attached to the forearm at the wrist joint. The five digits include the thumb and the four fingers, namely the index (IF), long (LF), ring (RF), and small finger (SF) (Fig. 1-1). The long and small fingers are often called the middle and little fingers, respectively. We believe that the term long finger is more appropriate to avoid the ambiguity as to what constitutes the middle finger. The use of little finger and long finger confuses their acronyms (LF); hence, small finger is preferred.

FIGURE 1-1

The hand has two surfaces—dorsal and palmar. The use of the term palmar should be restricted to the area limited by the glabrous skin, and the term volar should be used for areas proximal to it (see Fig. 1-1). Radial is used to describe direction toward the thumb and ulnar to describe direction toward the small finger, rather than lateral and medial (see Fig. 1-1). The palm has two eminences: the thenar eminence, which contains the intrinsic muscles of the thumb; and the hypothenar eminence, which contains the intrinsic muscles of the small finger (see Fig. 1-1). The connotation of the word intrinsic is to describe muscles that originate and insert in the hand, whereas extrinsic indicates muscles that originate outside the hand, such as the extrinsic finger flexors. The three well-defined creases of the hand are the thenar crease (forms the boundary of the thenar eminence), the proximal and distal palmar creases, and the distal wrist crease (forms the boundary of the glabrous skin) (see Fig. 1-1).

Each finger has three phalanges, namely proximal, middle, and distal, and three joints, namely metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP). The thumb has two phalanges, proximal and distal, and two joints, the MCP and the interphalangeal (IP). There are five metacarpals and five corresponding carpometacarpal (CMC) joints, which are numbered I to V from radial to ulnar. The first CMC joint is also known as the thumb basal joint (Fig. 1-2).

FIGURE 1-2

There are eight carpal bones arranged in roughly two rows. From radial to ulnar, the proximal row has the scaphoid, lunate, triquetrum, and pisiform, and the distal row has the trapezium, trapezoid, capitate, and hamate (Fig. 1-3). The bones of the distal row form the CMC joint with the base of the metacarpals and the midcarpal joint with the carpal bones of the proximal row. The proximal row articulates with the radius and the ulna. The palpable bony landmarks of the hand and wrist and their relation to the surrounding structures are depicted in Figure 1-4. The correct terminology to use when describing motion at the different joints of the hand is illustrated in Figure 1-5.

FIGURE 1-3

FIGURE 1-4

FIGURE 1-5

Examination/Imaging

Position

The patient is examined in the sitting position with elbows exposed and resting on a table in front. The examiner sits opposite the patient across the table (Fig. 1-6).

FIGURE 1-6

Procedure

We conduct our examination in stages (Table 1-1). In the first stage, we do a primary survey and focus on the hand as a whole, examining both hands. This stage begins by listening to the patient’s complaints and obtaining relevant history. This is followed by the basic examination strategy of look (inspection), feel (palpation), and move (range of motion).

The second stage is a more focused examination of one or more specific systems limited to the involved hand. The system to be examined is derived based on the primary survey. At the completion of the secondary survey, we should have a preliminary diagnosis or a differential diagnosis. If a diagnosis is not apparent, one should not make up a nebulous diagnosis such as tendinitis or arthritis. These made-up diagnoses may satisfy the patient’s need to have a reason for the discomfort but may label a patient erroneously when in fact there is no definite physiologic reason for the patient’s complaint. It is suitable to note that the patient has hand pain or wrist pain and occasionally to tell the patient that you do not know what is wrong when it is indeed truthful. We can share with the patient that we do not understand or know everything and are not able to cure every ailment.

Appropriate investigations are then ordered. The history and findings of the primary and secondary surveys are correlated with the investigations. If they do not match, a focused tertiary survey should be carried out to validate the investigation. A final diagnosis is then made and necessary treatment instituted.

Table 1-1 Systematic Examination of the Hand and Wrist

I Primary Survey (hand screen)—examine both hands 1 Listen (patient complaints and history) 2 Look 3 Feel 4 Move II Secondary Survey (system-specific examination)—examine involved hand 1 Assessment of muscle and tendon function 2 Assessment of nerve function 3 Assessment of vascular function 4 Assessment of bone and joint function III Preliminary Diagnosis and Differential Diagnosis IV Investigations V Tertiary Survey VI Final Diagnosis

Primary Survey

The aim of the primary survey is to perform a rapid assessment of both hands to determine whether all is well.

Look

The following three regions are inspected in turn:

Palmar aspect of hand and volar forearm (Fig. 1-7)

• Fingers extended

♦ Swelling, erythema, bruising, color changes, or scars

♦ Deformity, abnormal finger posture, or amputation

♦ Wasting (thenar, hypothenar, or forearm)

• Fingers flexed

♦ Active range of joint motion

♦ Triggering

♦ Abnormal finger posture

♦ Scar adhesions during movement

Dorsal aspect of hand and forearm (Fig. 1-8)

• Hand

♦ Swelling, erythema, bruising, color changes, or scars

♦ Nail changes

♦ Wasting (first web space and intermetacarpal space)

• Dorsal aspect of forearm and elbow

♦ Swelling, erythema, bruising, color changes, or scars

♦ Wasting

• Active range of wrist motion (flexion, extension, radial and ulnar deviation, and pronosupination)

FIGURE 1-7

FIGURE 1-8

Feel

Vascularity

• Do all digits feel warm?

• Can you feel a radial pulse (Fig. 1-9)?

• Check capillary refill

Sensation (Fig. 1-10)

• Lateral aspect of midarm (C5 dermatome)

• Dorsum proximal phalanx of thumb (radial nerve, C6 dermatome)

• Tip of long finger (median nerve, C7 dermatome)

• Tip of small finger (ulnar nerve, C8 dermatome)

• Medial aspect of elbow (T1 dermatome)

Motor function (Fig. 1-11)

• Palmar abduction of thumb—abductor pollicis brevis (APB) (median nerve)

• Crossing long finger over index finger—interossei (ulnar nerve)

• Raising thumb off table—extensor pollicis longus (EPL) (radial nerve)

Autonomic function

• Skin dry?

Tenderness

• Localization of specific points of tenderness

FIGURE 1-9

FIGURE 1-10

FIGURE 1-11

Move

Assess passive range of motion

• Thumb IP and MCP joints

• Finger IP and MCP joints

• Wrist (flexion, extension, radial and ulnar deviation, and pronosupination)

♦ The normal range of motion at the different joints of the hand and wrist has been summarized in Tables 1-2 and 1-3, respectively. Extension should be measured with the goniometer placed palmar, whereas flexion is measured with the goniometer placed dorsally (Fig. 1-12). Radial and ulnar deviation of the wrist is measured with the goniometer placed along the long finger and dorsal aspect of the distal radius (Fig. 1-13). Pronation and supination should be measured with the elbow in 90 degrees flexion and the arms firmly pressed against the outer ribs (Fig. 1-14).

• At the completion of the primary survey, if something appears abnormal, one should proceed to a secondary survey. The primary survey should be able to guide us toward the anatomic system that is problematic. For example, a patient presents with history of numbness of the left thumb and index finger, and the primary survey finds diminished sensation of the left long finger tip and weakness in palmar abduction of the left thumb. The secondary survey should therefore focus on examination of the left median nerve.

Table 1-2 Normal Range of Digital Motion

Table 1-3 Normal Range of Wrist Motion

FIGURE 1-12

FIGURE 1-13

FIGURE 1-14

For an expanded version of this chapter, please see www.expertconsult.com.

Secondary Survey

The aim of the secondary survey is to do a focused examination of the anatomic system suspected by primary survey to reach a diagnosis or a differential diagnosis. We have divided the anatomic systems of the hand and wrist into four groups: (1) muscle and tendon, (2) nerve, (3) vascular, and (4) bone and joint. The following sections discuss the examination of common pathologic conditions of the hand involving these four systems and describe the various signs and provocative tests that are helpful in diagnosis. One should remember to test both hands and compare patient responses between the two sides.

Assessment of Tendon and Muscle Function

Tendinopathy: This includes a wide group of painful conditions affecting the tendons of the wrist and hand. They can be broadly classified into tenosynovitis (inflammation of the synovial lining of the tendon sheath), tendovaginitis (inflammation of the retinacular lining of the tendon sheath), tendinitis (inflammation of the tendon), tendinosis (degeneration of the tendon), and tendon subluxation.

• Tenosynovitis: This can result from infections (suppurative flexor tenosynovitis, tuberculosis, or atypical mycobacterial, gonococcal, or fungal infection) or chronic diseases (rheumatoid arthritis, gout, pseudogout, amyloidosis, or sarcoidosis). Kanavel described four cardinal signs of acute suppurative flexor tenosynovitis: a semi-flexed position of the finger, symmetrical enlargement of the whole digit (fusiform swelling), tenderness limited to the course of the flexor tendon sheath, and excruciating pain along the flexor sheath on passively extending the finger (Fig. 1-15). The chronic presentation of tenosynovitis can be identified by three findings: swelling of the palmar aspect of the digit, discrepancy between active and passive range of motion, and palpable crepitus along the course of the flexor tendon on active and passive flexion of the digit. Figure 1-16 shows a patient with rheumatoid chronic tenosynovitis. On inspection, it appears similar to acute suppurative tenosynovitis, but there is no pain on passive extension.

FIGURE 1-15

FIGURE 1-16

• Tendovaginitis: This is caused by narrowing of the retinacular sheath of the tendon. Vaginitis is a preferred term because the inflammation is not in the tendon but in the tendon sheath. The two common presentations are trigger digits and de Quervain disease. Rarely, patients present with tendovaginitis involving the EPL tendon in the third dorsal wrist compartment at Lister tubercle and the extensor indicis proprius (EIP) and extensor digiti minimi (EDM) tendons in the fourth and fifth dorsal wrist compartments.

♦ Trigger digits: The grade of triggering should be recorded for follow-up purposes (Table 1-4). One should look for tenderness over the A1 pulley and a palpable nodule. In long-standing triggers, a flexion contracture of the PIP joint may be present, and the degree of contracture should be noted.

Table 1-4 Grading of Trigger Digits

Grade I	Pretriggering	History of triggering, but not demonstrable on examination
Grade II	Active	Demonstrable triggering, but patient can actively overcome the trigger
Grade III	Passive	Demonstrable trigger, but patient cannot actively overcome trigger
IIIA	Extension	Locked in flexion and needs passive extension to overcome trigger
IIIB	Flexion	Locked in extension and needs passive flexion to overcome trigger
Grade IV	Contracture	Demonstrable trigger with flexion contracture of proximal interphalangeal joint

♦ de Quervain disease: The patient has tenderness over the radial styloid and may have triggering of the thumb extensor tendons. The following tests can be done to confirm the presence of de Quervain disease.

• Hitchhiker’s sign: The patient complains of pain localized to the first dorsal compartment when asked to extend and abduct the thumb, as is done when requesting a ride (Fig. 1-17).

FIGURE 1-17

• Finkelstein test: This is done by grasping the patient’s thumb and ulnar-deviating the wrist (Fig. 1-18). This usually results in acute pain over the radial styloid.

FIGURE 1-18

FIGURE 1-19

FIGURE 1-20

♦ Extensor carpi ulnaris (ECU) tendinitis: The patient has tenderness and crepitus along the ECU sheath and complains of pain on active resisted wrist extension and ulnar deviation. The following test has been described to differentiate between intra-articular and extra-articular pathology:

• ECU synergy test: The patient rests the arm on the examining table with the elbow flexed at 90 degrees and the forearm in full supination. The wrist is held in neutral position with the fingers in full extension. Facing the patient, the examiner grasps the patient’s thumb and long finger with one hand and palpates the ECU tendon with the other hand. The patient then radially abducts the thumb against resistance (Fig. 1-21). The presence of both flexor carpi ulnaris (FCU) and ECU muscle contraction is confirmed by direct palpation as the tendon bowstrings under the fingertips. Re-creation of pain along the dorsal ulnar aspect of the wrist is considered to be a positive test for ECU tendinitis.

FIGURE 1-21

FIGURE 1-22

Tendon injury: A tendon injury can result from an open wound or rupture after sustaining sudden force or from chronic attrition. The zones of acute flexor and extensor tendon injuries have been depicted in Figure 1-23. The normal finger cascade is lost with tendon injury. Figure 1-24 shows the attitude of the hand with a zone 1 flexor digitorum profundus (FDP) injury, and Figure 1-25 shows the attitude of the hand in a patient with attritional rupture of the extensor tendons to the ring and small fingers. The presence of tendon injury is confirmed by asking the patient to actively flex or extend the digits. A partial tendon laceration should be suspected in patients in whom active motion is associated with pain or triggering. In patients who cannot cooperate (e.g., children, comatose or intoxicated patients), one can look for passive movement of the fingers resulting from the wrist tenodesis effect (Fig. 1-26) or elicited by squeezing the forearm muscles (Fig.1-27). The same maneuvers can be used when trying to differentiate between tendon injury and an inability to move as a result of nerve palsy.

FIGURE 1-23

FIGURE 1-24

FIGURE 1-25

FIGURE 1-26

FIGURE 1-27

FIGURE 1-28

Table 1-5 Classification of Flexor Digitorum Profundus (FDP) Avulsion Injuries

FIGURE 1-29

FIGURE 1-30

FIGURE 1-31

FIGURE 1-32

FIGURE 1-33

FIGURE 1-34

FIGURE 1-35

FIGURE 1-36

FIGURE 1-37

FIGURE 1-38

FIGURE 1-39

FIGURE 1-40

FIGURE 1-41

Table 1-6 Burton Classification of Chronic Boutonnière Deformity

An assessment of the results of tendon repair is done by calculating total active motion (TAM). TAM = total active flexion (MCP + PIP + DIP joints) − total extension deficit (MCP + PIP + DIP joints). The TAM in a repaired finger can be compared with the values obtained in the uninjured contralateral finger (American Society for Surgery of the Hand [ASSH] grade) or presented as a percentage (Strickland and modified Strickland grades) (Table 1-7).

Assessment of Nerve Function

General assessment: The assessment of nerve function involves testing for sensory, motor, and autonomic function. The British Medical Council grading of motor and sensory function has been detailed in Table 1-8 and Table 1-9, respectively. The branches of the brachial plexus with root values have been depicted in Figure 1-42. Figure 1-43 shows an easy way to draw the brachial plexus. (Adapted with permission from Edwards Jr GS. ASSH Correspondence Newsletter. 1991:103.) Two additional signs are useful in following the progress of nerve regeneration. They are the Tinel sign and the tender muscle sign.

Table 1-8 Medical Research Council Grading of Muscle Function

Grade M0	No contraction
Grade M1	Palpable contraction, no movement
Grade M2	Movement with gravity eliminated
Grade M3	Movement against gravity
Grade M4	Movement against resistance
Grade M5	Normal

Table 1-9 Medical Research Council Grading of Sensory Function

Grade S0	No sensation
Grade SI	Deep pain
Grade S2	Superficial pain and some touch
Grade S3	Grade S2 without over-response
Grade S3+	Grade S2 with some two-point discrimination
Grade S4	Normal

FIGURE 1-42

FIGURE 1-43

• Two-point discrimination (2-PD): The measurement of static 2-PD is useful in determining tactile discrimination (number of innervated sensory receptors) for the slowly adapting sensory receptors (Merkel cell neurite complex and Ruffini end organs). It is measured with an instrument known as the Disk-Criminator (Lafayette Instrument Company, Lafayette, Ind). Normal values of static 2-PD for the different areas of the hand are shown in Table 1-10. It is applied with just enough pressure to cause capillary blanching. A paper clip can be used for quick evaluation of 2-PD if a Disk-Criminator is not available.

• Tinel sign: This is elicited by lightly percussing along the course of the affected nerve from distal to proximal. When the finger percusses over the zone of regenerating fibers, the patient will indicate the sensation of pins and needles in the cutaneous distribution of the nerve. The advance of the regenerating axons down the nerve can be followed by studying the advance of the Tinel sign. In general, a strongly positive Tinel sign over a lesion soon after injury indicates rupture or severance. If a nerve repair is going to be successful, the distally moving Tinel sign is persistently stronger than that at the suture line, and if the repair is going to fail, the Tinel sign at the suture line remains stronger. A failure of distal progression of the Tinel sign in a closed lesion indicates rupture or other lesion impeding regeneration.

• Tender muscle sign: This sign is elicited by squeezing the muscle that is being examined. The pain felt is distinctive and is different from a skin sensation. It feels like a deep and acid ache and always produces a characteristic wince in the patient. This pain can be differentiated by doing a similar squeeze on the normal side. It is similar to the pain experienced when having a muscle cramp. It follows a Tinel sign that has progressed into a muscle and appears before evidence of grade 1 power.

• Assessment of autonomic function: The moisture of the skin can give useful information about the lesion. Dry skin in an anesthetic area suggests a postganglionic lesion; on the contrary, normal moist skin suggests a preganglionic lesion. Sliding a plastic pen over the skin of the affected limb and comparing it with the normal side can be used to test sweating function of the skin.

• Wrinkle test: A hand placed in warm water (40° C for 30 minutes) does not wrinkle in the denervated area as normal skin does. This test is useful in small children unable to respond to other tests.

Assessment of individual nerves: The different provocative tests and signs available for diagnosis of median, ulnar, and radial nerve palsy are described next. It is useful to perform the nerve percussion test at points where nerves are not anatomically located as a negative control, especially in patients who are hyper-responsive to stimuli or have positive nerve percussion test results at multiple entrapment sites.

• Median nerve

♦ Carpal tunnel syndrome (CTS): The following provocative tests have been used in the diagnosis of CTS.

• Tinel sign: This is done by applying repeated digital percussion over the median nerve at the level of the proximal edge of the transverse carpal ligament (TCL) (in line with the pisiform) medial to the FCR tendon (over the PL tendon if present) (Fig. 1-44). This should elicit the sensation of pins and needles in the cutaneous distribution of the median nerve.

FIGURE 1-44

• Phalen test: This is done by holding the wrist in maximal flexion for 60 seconds. It is believed to compress the median nerve between the proximal edge of the TCL and the underlying flexor tendons and should elicit a pins and needles sensation in the median nerve sensory distribution (Fig. 1-45). A modification of this test has been described, in which the wrist is held in maximal extension (reverse Phalen test) (Fig. 1-46).

FIGURE 1-45

FIGURE 1-46

• Carpal compression test (Durkan test): This is done by applying direct digital pressure over the median nerve for 30 seconds (at the same site as described for the Tinel sign) and is considered positive when symptoms are reproduced. It has also been combined with the Phalen and reverse Phalen test (Fig. 1-47).

FIGURE 1-47

• Scratch collapse test: This is a recently introduced test and relies on loss of muscle strength (shoulder external rotation), which is independent of the compressed nerve and therefore provides an outcome unrelated to the site of nerve compression. It is performed with the patient facing the examiner, with arms adducted, elbows flexed, and both hands outstretched and with wrists at neutral position. The patient is asked to perform simultaneous resisted bilateral shoulder external rotation, keeping the arms abducted. The examiner gently pushes against both of the patient’s forearms, asking the patient to sustain steady resistance. With fingertips, the examiner then scratches or swipes the skin overlying the median nerve over the carpal tunnel (or any potentially compressed nerve) (Fig. 1-48). A positive scratch collapse test is recorded for the median nerve if the patient demonstrates a momentary loss of external resistance tone on the affected side after scratching over the carpal tunnel. This loss of muscle resistance is quite brief, and the patient regains strength almost immediately. The mechanism of this test is not very well understood, but it is believed to be due to a temporary inhibition of tonic voluntary muscle activity, in response to painful cutaneous stimuli.

FIGURE 1-48

• Strength testing of APB: This is tested by asking the patient to place the thumb perpendicular to the palm (palmar abduction) (grade 3 power). In patients who are able to do this, the examiner tries to push the thumb palmar with the patient trying to resist it (grade 4/5). It is better to place a book or wall along the radial border of the hand to prevent the thumb from going into radial abduction as a result of APL contraction (Fig. 1-49).

FIGURE 1-49

♦ Pronator syndrome: This results from compression of the median nerve in the forearm, and patients present with sensory symptoms similar to CTS. However, these patients also complain of aching pain in the proximal volar forearm and have sensory loss in the distribution of the palmar cutaneous branch of the median nerve (thenar eminence). In addition, none of the provocative tests for CTS are positive. The likely site of compression can be determined by one of the following provocative tests:

• Resisted forearm pronation test: The patient’s forearm is placed in full supination with the wrist in neutral position. The examiner then resists the patient’s attempt to pronate the forearm. If pain or paresthesia is reproduced during this maneuver, one should suspect entrapment of the median nerve at the level of pronator teres.

• Resisted FDS middle finger test: Pain or paresthesia with resisted flexion of the long finger FDS is suggestive of median nerve compression at the level of the fibrous arch between the heads of the FDS (Fig. 1-50).

FIGURE 1-50

• Resisted elbow flexion test: Pain or paresthesia with resisted flexion of the elbow with the forearm in supination suggests compression of the median nerve by the lacertus fibrosis (Fig. 1-51).

FIGURE 1-51

♦ Anterior interosseous nerve (AIN) syndrome: Unlike the previous two median nerve compression disorders, which are predominantly sensory, the AIN is a pure motor nerve. The patient may have weakness or palsy of the FPL, FDP to the index and long figures, and pronator quadratus (PQ). The following tests may be used to determine the presence of AIN palsy.

• OK sign: Patients are unable to make an OK sign when asked by the examiner to flex the thumb IP joint and index finger DIP joint (Fig. 1-52).

FIGURE 1-52

• Paper pinch sign: Asking patients with weak FPL and FDP (but not palsy) to pinch a sheet of paper between the thumb and index finger using only the fingertips and then trying to pull the paper away can determine subtle weakness of the FPL and index finger FDP. The patient will be unable to hold on to the sheet of paper with just the fingertips and may compensate by using a more adaptive grip in which the IP joint of the thumb and DIP joint of the index finger remain extended (Fig. 1-53).

FIGURE 1-53

• PQ assessment: The PQ is tested by checking the ability of the patient to pronate the forearm with the elbow in maximal flexion. Maintaining the elbow in flexion minimizes the contribution of the pronator teres (PT) (Fig. 1-54).

FIGURE 1-54

• Ulnar nerve

♦ Compression in Guyon canal: The provocative tests for assessment of ulnar nerve compression at Guyon canal are similar to those for CTS and include direct compression of the ulnar nerve immediately radial to the pisiform and the reverse Phalen test. The patient will have symptoms in the distribution of the ulnar nerve. Loss of sensation on the dorsoulnar aspect of the hand, which is innervated by the dorsal branch of the ulnar nerve, can help differentiate a high ulnar nerve lesion (e.g., cubital tunnel compression) from a low ulnar nerve lesion (e.g., Guyon canal compression), in which sensation should be preserved over the dorsoulnar hand. The following signs and tests have been described to identify loss of ulnar nerve motor function:

• Claw deformity (Duchenne sign): This is the characteristic resting posture of the ring and small fingers with hyperextension of the MCP joint and flexion of the IP joint (Fig. 1-55). It results from the unopposed action of the radial nerve–innervated long extensors at the MCP joint (hyperextension) and median nerve–innervated FDS at the PIP joint (flexion) in the presence of the paralyzed ulnar nerve–innervated interosseous and the third and fourth lumbricals that normally flex the MCP joint and extend the PIP joint. The MCP joint hyperextension deformity may not appear immediately after an ulnar nerve injury and depends on the laxity of the MCP joint volar plate. The deformity is more pronounced in patients with a lax volar plate and develops over time in patients with a taut volar plate or thick palmar skin, as in a manual laborer.

FIGURE 1-55

• Cross-your-fingers test: The patient is asked to cross the long finger dorsally over the index finger or the index finger over the long finger. In ulnar nerve palsy, the patient will be unable to do so because of paralysis of the interossei.

• Middle finger abduction (Pitres-Testut sign): This is inability to abduct the long finger from side to side.

• Wartenberg sign: The small finger is abducted at rest (Fig. 1-56). This deformity results from unopposed action of the radial nerve–innervated EDM in the presence of the paralyzed ulnar nerve–innervated third palmar interosseous that normally adducts the small finger. The EDM causes abduction of the small finger in addition to extension because it has an insertion on the ulnar aspect of the base of the proximal phalanx.

FIGURE 1-56

• Froment sign: The patient is asked to pinch sheets of paper between the thumb and index finger of both hands. A positive Froment sign is indicated by marked thumb IP joint flexion in the affected hand as a result of the patient using his median nerve–innervated FPL to hold the sheet of paper, rather than using the adductor pollicis (Fig. 1-57).

FIGURE 1-57

♦ Cubital tunnel syndrome: In addition to all the signs mentioned previously, the patient will have loss of sensation on the dorsoulnar aspect of the hand and weakness of the FCU and FDP to the ring and small fingers. In high ulnar palsy, the claw deformity appears less severe because the FDP tendons to the ring and small fingers are paralyzed, so there is no longer any deforming force at the DIP joint (ulnar nerve paradox). The scratch collapse test (described with CTS) and the elbow flexion test have been used as provocative tests in cubital tunnel syndrome.

• Elbow flexion test: The elbow is placed in full flexion with the wrist in hyperextension, and digital pressure is applied to the ulnar nerve midway between the medial epicondyle and the olecranon for 60 seconds (Fig. 1-58). Pins and needles sensation in the ring and small fingers is suggestive of cubital tunnel syndrome.

FIGURE 1-58

• Radial nerve

♦ Compression of superficial radial nerve (Wartenberg syndrome): The superficial sensory branch of the radial nerve pierces the deep fascia of the forearm between the brachioradialis (BR) and the ECRL to enter the subcutaneous plane about 6 to 9 cm proximal to the radial styloid. In addition to a positive Tinel sign at the point of emergence of the nerve from the deep fascia and occasionally a positive Finkelstein test, the following provocative test is useful in confirming the diagnosis:

• Forearm pronation and ulnar deviation test: The elbow and wrist are extended, and the forearm is pronated. The wrist is then ulnar deviated, and the development of paresthesia in the superficial radial nerve distribution within 60 seconds is suggestive of nerve compression (Fig. 1-59).

FIGURE 1-59

♦ Proximal radial nerve versus proximal interosseous nerve (PIN) compression or palsy: Proximal radial nerve palsy (above the elbow) is characterized by an inability to extend the wrist and finger metacarpophalangeal joints and to extend and abduct the thumb. In PIN palsy (below the elbow), the ECRL is spared because it receives its innervation by a branch of the radial nerve that arises above the elbow. Patients can extend the wrist, although with radial deviation (Fig. 1-60). Additionally, sensory loss in the areas innervated by the superficial radial nerve (anatomic snuffbox and dorsum of first web) can help differentiate a radial nerve lesion from a lesion of the PIN, in which sensation should be preserved over the dorsum of the first web.

FIGURE 1-60

♦ Radial tunnel syndrome: The radial tunnel refers to the segment of the radial nerve between the lateral intermuscular septum and the supinator. Patients with radial tunnel syndrome present with aching pain in the proximal radial part of the forearm, and it is often confused with the much more common lateral epicondylitis. The following provocative tests have been described for the diagnosis of radial tunnel syndrome:

• Supinator compression test: Compression of the radial nerve 5 cm distal to the lateral epicondyle reproduces the characteristic pain (Fig. 1-61).

FIGURE 1-61

• Resisted supination test: The patient keeps the elbow flexed and the forearm in pronation. The patient is then asked to extend the elbow and supinate the forearm, while the examiner tries to maintain the forearm in pronation. This compresses the nerve under the arch of the supinator and reproduces the symptoms.

• Resisted long finger extension test: The patient tries to extend the long finger against resistance with the elbow and wrist in extension. This sign results from pressure being transmitted through the long finger metacarpal and the insertion of the ECRB to the fibrous edge of the muscle overlying the radial nerve in the tunnel (Fig. 1-62).

FIGURE 1-62

Assessment of Vascular Function

General assessment: The entire upper extremity and neck should be evaluated, and it is important to compare both sides. The fingertip is examined for color, capillary refill (normal is <2 seconds), turgor, and nail changes (loss of normal sheen and fungal infections). The extremity should be evaluated for the presence of ulcers and gangrene (dry or wet). Palpation and auscultation of visible masses overlying the course of the major vessels can detect pulsations, thrill, and bruits.

Specific maneuvers

• Peripheral pulsations: The presence or absence and quality of pulsations of the radial, ulnar, brachial, and axillary arteries should be recorded bilaterally. The radial and ulnar arteries are palpated in the distal aspect of the volar forearm, radial to the FCR tendon and ulnar to the FCU tendon, respectively. The brachial artery is palpated immediately proximal to the elbow flexion crease medial to the biceps tendon. It may be easier to identify the tendon with the elbow in flexion and to palpate the artery with the elbow in extension. The axillary artery is palpated high in the axilla against the humerus. The location of the artery can be identified by asking the patient to adduct the arm against resistance. This tenses the pectoralis and coracobrachialis muscles. The axillary pulsations can be easily felt in the groove between these two muscles. The pulsations of digital arteries are difficult to palpate. This palpation is best carried out by holding each finger separately at the base between the index finger and thumb in such a manner that a palpating finger is positioned over the digital artery on both sides.

• Allen test: As per the original description, the examiner palpates both radial arteries with the thumb while supporting the wrist with the fingers. The subject is then asked to close the hand as tightly as possible to squeeze the blood out of the hand. The examiner then occludes the radial artery by compressing the wrist between the thumb and the fingers. The patient next opens the hand partially while the examiner maintains compression of the radial artery (Fig. 1-63). The examiner observes for return of color to the hand. A delay in return of color to the hand suggests obstruction of collateral flow through the ulnar artery or the presence of an incomplete palmar arch. Although no specific time has been mentioned, a delay of greater than 5 seconds should be considered significant. A modification of this test was introduced by Wright, which involves the examiner occluding the patient’s ulnar and radial arteries while the patient makes a fist, causing the hand to blanch. The patient is then asked to extend the fingers (Fig. 1-64). After the hand is open, the examiner releases the ulnar artery while continuing to maintain pressure on the radial artery. Adequate collateral circulation is indicated by return of normal color to the hand. Both the Allen and modified Allen tests may be repeated by maintaining compression on the ulnar artery and releasing the radial artery. With both tests, it is important to tell the patient not to hyperextend the fingers but rather to open the hand partially because hyperextension could cause a decrease in perfusion to the arch (Fig. 1-65), possibly resulting in a false interpretation of the Allen test. It is better to report the result of the Allen test in terms of the radial and/or ulnar arteries being patent or occluded instead of positive or negative to avert any misunderstanding.

FIGURE 1-63

FIGURE 1-64

FIGURE 1-65

• Digital Allen test: This is performed by compressing both digital arteries at the base of the finger using the index finger and thumb (Fig. 1-66). The patient is asked to elevate the hand and fully flex the finger several times. This will result in a blanched finger. The hand is then lowered, and the compression on one of the digital arteries is released. If the finger continues to remain blanched when only one digital artery is compressed, the opposite digital artery must be divided or occluded. The test can be be repeated to check the other digital artery.

FIGURE 1-66

Assessment of Bone and Joint Function

General assessment: Displaced fractures and unreduced dislocations are usually quite obvious because of the associated deformity. However, the assessment of undisplaced or minimally displaced fractures and of partial or complete ligament injuries without dislocation or after reduction of a dislocation can be difficult, especially because of the associated pain and swelling. Gentle palpation can pinpoint specific sites of tenderness that can be correlated with the radiographs. A local anesthetic block may occasionally be required for accurate, painless assessment of joint stability and stress radiographic views. A simple classification of IP and MCP joint collateral ligament injuries is provided in Table 1-11.

Table 1-11 Classification of Collateral Ligament Injuries

Grade I	Pain, no laxity
Grade II	Laxity, but a firm end point, stable arc of motion
Grade III	Grossly unstable, no firm end point

Assessment of specific bones

• Scaphoid fracture: Patients may have tenderness in the anatomic snuffbox, and the normal concavity of the anatomic snuffbox may be obliterated as a result of effusion in the wrist joint. There may also be tenderness over the scaphoid tubercle, and the Watson scaphoid shift test (described in the section on scapholunate instability) may elicit pain. The following provocative tests have been described for diagnosis of scaphoid fractures:

♦ Pain with resisted pronation: The patient is asked to hold the examiner’s hand and attempt pronation while the examiner resists it. This provokes a distinct pain in the region of the scaphoid. This pain can also be reproduced by pronation followed by gentle ulnar deviation.

♦ Thumb axial compression test: This is done by holding the patient’s thumb in a chuck grip above the thumb MCP joint and providing a compression force down the axis of the thumb (Fig. 1-67).

FIGURE 1-67

• Hook of hamate fracture: Patients have deep tenderness in the palm over the hook of the hamate. The hook of the hamate is the first bony prominence felt along a line drawn from the pisiform to the index finger MCP joint. It is approximately 2 cm distal and radial to the pisiform. Patients with a late presentation may have ulnar nerve paresthesia into the ring and small fingers, weakened grip strength, and, rarely, rupture of the ring or small profundus or superficialis flexor tendons. The following provocative test has been used in diagnosis of hook of hamate fractures:

♦ Resisted ring and small finger flexion test: Pain with resistance of ring and small finger flexion that is greater with the wrist in ulnar deviation and lessened by radial deviation results from irritation of the flexor tendons to the ring and small fingers caused by the fractured hook of the hamate.

♦ Kienböck disease: Patients may have swelling and tenderness just distal and ulnar to Lister tubercle. They will also have pain with wrist flexion, extension, forced axial loading of the wrist, and resisted extension of the long finger (described in the section on scapholunate instability).

Assessment of specific joints

• Thumb carpometacarpal joint arthritis: Patients present with swelling and tenderness at the thumb basal joint. In the later stages of the disease process, patients have the classic dorsal subluxation of the thumb CMC joint with associated web space adduction and MCP joint hyperextension deformity (Z-deformity). The following provocative tests are useful in clinical diagnosis in the early stages:

♦ Distraction test: Distraction of the CMC joint by traction of the thumb causes a subjective improvement in pain in the early stages of the disease.

♦ Grind test: An axially directed force applied to the thumb metacarpal with the MCP joint flexed and rotated like a crank will cause pain and palpable crepitus owing to the synovitis and increased contact between the arthritic surfaces of the CMC joint (Fig. 1-68).

FIGURE 1-68

• Carpal boss (second and third CMC joint arthritis): This is usually a result of osteoarthritis involving the second and/or third CMC joints. Patients present with a tender dorsal mass. The following provocative tests have been described:

♦ Metacarpal distraction stress test (Fusi): Pain at the level of the second and third CMC joints elicited by distracting the index and middle metacarpals while simultaneously attempting to supinate and pronate them with the MCP joint held in flexion (Fig. 1-69).

FIGURE 1-69

♦ Metacarpal compression stress test (Linscheid test): Pain is elicited by providing axial compression along the axis of the second and third metacarpals (Fig. 1-70).

FIGURE 1-70

• Wrist joint: The following two provocative tests have been described for global assessment of wrist pain. They suggest that the patient has significant wrist pathology causing the pain. These tests are useful in patients when the history and examination findings do not match. However, they do not indicate the location or nature of the pathology.

♦ Carpal shake test: This involves grasping the patient’s distal forearm and passively shaking or passively extending and flexing the wrist. Lack of patient resistance or complaints suggests a low level of carpal pathology.

♦ Sitting hand test: The patient is asked to support his/her weight off the chair while seated. This maneuver produces stress across the wrist, and patients with wrist pathology find it difficult to perform this.

• Scapholunate (SL) instability: Patients with injury to the SL ligament present with dorsal wrist swelling and tenderness immediately distal to the Lister tubercle. One or more of the following provocative tests may be positive depending on the degree of injury to the SL ligament and integrity of the secondary stabilizers.

♦ Scaphoid shift test (Watson): With the patient’s forearm in slight pronation, the examiner places the thumb on the scaphoid tuberosity and wraps the fingers around the distal radius. The examiner’s other hand controls wrist position by grasping the patient’s hand at the metacarpal level. The wrist is moved passively from a position of ulnar deviation and slight extension into a position of radial deviation and slight flexion while maintaining constant pressure on the scaphoid tuberosity. In ulnar deviation, the scaphoid is extended (scaphoid axis is in line with long axis of forearm), whereas in radial deviation, the scaphoid is flexed (scaphoid axis is more perpendicular to long axis of forearm). Pressure on the tuberosity while the wrist is moved from ulnar deviation to radial deviation prevents the scaphoid from flexing. In such circumstances, if the SL ligaments are completely insufficient or torn, the proximal pole subluxates dorsally out of the scaphoid fossa and onto the dorsal rim of the radius, inducing pain on the dorsoradial aspect of the wrist. When pressure is released, a typical thunk may occur, indicating an abrupt reduction of the scaphoid to its normal position. In patients with rigid periscaphoid ligamentous support, the scaphoid rotates normally and pushes the examiner’s thumb out of the way. The response of most patients is somewhere between these two extremes.

♦ Resisted long finger extension test: The patient is asked to extend the long finger fully against resistance with the wrist partially flexed. This compresses any areas of synovitis under the tendon and causes pain. If the pain occurs over the SL joint, it is suggestive of SL pathology. This maneuver is very sensitive but not specific (Fig. 1-71).

FIGURE 1-71

♦ SL ballottement test (Shear test or lift test; Dobyns test): The lunate is firmly stabilized with the thumb and index finger of one hand while the scaphoid, held with the other hand (thumb on the palmar tuberosity and index on the dorsal proximal pole), is displaced dorsally and palmar with the other hand. A positive result elicits pain, crepitus, and excessive mobility of the scaphoid.

• Lunotriquetral (LT) instability: Patients present with ulnar-sided wrist pain that is aggravated by ulnar deviation and supination. The following provocative tests have been described for diagnosis of LT instability:

♦ LT ballottement test (shuck test; Reagan test): The forearm is held in neutral rotation, and the lunate is firmly stabilized with the thumb and index finger of one hand while the triquetrum and pisiform are displaced dorsally and then palmar with the other hand. A positive result elicits pain, crepitus, and/or laxity of the joint.

♦ LT shear test (Kleinman test): The forearm is held in neutral rotation, and the examiner stabilizes the lunate with the thumb placed over the dorsum of the lunate, deep to the extensor digitorum communis tendons and just distal to the distal edge of the dorsal radius. The examiner then uses the other thumb to push the pisiform dorsally from the palmar side, creating a shear force at the LT joint that causes pain. A click may be elicited in patients by moving the wrist into radial and ulnar deviation.

♦ Derby test: The patient’s wrist is extended and radially deviated with the forearm in full pronation. The examiner then pushes the palmar surface of the pisiform with the thumb and provides counterpressure with the fingers on the dorsum of the ulna. While maintaining pressure on the pisiform, the patient’s wrist is brought into a neutral position. In patients with LT instability, this maneuver is accompanied by a click and reduces the triquetrum. Patients should be asked whether the previous feeling of instability has disappeared, and to make a clenched fist. A distinct improvement in grip strength should be noted at this point for a positive test.

♦ Ulnar snuffbox compression test (Linscheid test): This involves applying pressure over the ulnar aspect of the triquetrum on the dorsum of the wrist (palmar to the ECU and distal to the ulnar styloid), with the wrist in radial deviation (Fig. 1-72). If this pressure reproduces the patient’s symptoms, either an LT injury or an ulnar styloid–triquetrum impingement syndrome should be suspected. One must take care to distinguish this test from the ulnar foveal sign (for triangular fibrocartilage complex [TFCC] injuries) and the ulnar head compression test (for distal radioulnar [DRU] joint synovitis and arthritis; described later).

FIGURE 1-72

• DRU joint instability: Many signs and provocative tests have been described for diagnosis of DRU joint instability and TFCC injuries.

♦ Piano key sign: This maneuver is performed with the forearm in a pronated position resting on a table. The ulnar head is depressed (Fig. 1-73). In patients with DRU joint instability, the ulnar head can easily be depressed and springs back into position like a piano key.

FIGURE 1-73

♦ Radioulnar ballottement test: The distal radius is stabilized between the thumb and fingers of one hand, and the distal ulna is grasped and moved in a volar to dorsal direction with the other hand (Fig. 1-74). Excessive motion and/or pain compared with the other wrist is indicative of DRU joint instability. This maneuver is performed with the forearm in neutral, supinated, and pronated positions. More laxity normally occurs in the neutral position than in either pronation or supination because the joint capsule tightens as the limits of both motions are approached. It is essential to compare with the contralateral extremity because the normal range of motion and laxity of the DRU joint vary considerably among individuals.

FIGURE 1-74

♦ Press test: The patient rises from a chair using the hands for assistance by pushing against a tabletop located in front of him or her. DRU joint instability is shown by greater depression of the ulnar head on the affected side and is often associated with pain.

♦ Ulnar foveal sign: This test is performed with the elbow flexed and the examiner supporting the patient’s wrist and hand, maintaining the forearm in neutral rotation and the wrist in neutral position. The examiner then presses the thumb distally and deep into the interval soft spot between ulnar styloid and pisiform. The foveal sign is positive when there is exquisite tenderness compared with the contralateral side and when it replicates the pain felt by the patient. This test is sensitive in the diagnosis of foveal detachment of the TFCC and ulnotriquetral ligamentous injuries (Fig. 1-75).

FIGURE 1-75

♦ Ulnar compression test: This test is performed with the elbow in flexion and the forearm in neutral position. A radially directed force is applied to the ulnar head to compress it against the sigmoid notch (Fig. 1-76). Patients with DRU joint synovitis or arthritis will complain of pain over the DRU joint.

FIGURE 1-76

♦ Ulnocarpal stress test (TFCC grind test): The wrist is maintained in maximal ulnar deviation, and the examiner axially loads it while passively pronosupinating the wrist (Fig. 1-77). The test is positive when patient has ulnar-sided wrist pain during this maneuver. This test is positive in patients with ulnocarpal abutment syndrome and TFCC injuries.

FIGURE 1-77

• Ulnocarpal instability: These patients usually present with volar sag and carpal supination and often have an associated TFCC injury. The provocative tests described for diagnosis of ulnocarpal ligament injury include, in addition to the ulnar foveal sign, the pisiform boost test and the relocation test.

♦ Pisiform boost test: Dorsally directed pressure on the palmar surface of the pisiform reduces the carpus on the ulna and results in crepitus, clicking, and/or pain.

♦ Relocation test (Prosser test): This test involves the combined movement of pronation and dorsal translation of the carpus onto the ulna. This relocates the carpus into normal alignment and may reduce the patient’s pain.

• Midcarpal instability: Patients with midcarpal instability present with pain, swelling, and tenderness on the ulnar midcarpal region (triquetrohamate articulation). They have characteristic volar sag of the carpus on the ulnar side and a clunk as the wrist moves from radial to ulnar deviation. The midcarpal shift test is diagnostic of midcarpal instability.

♦ Midcarpal shift test (Lichtman test): This test is performed by applying an axial load to a pronated, slightly flexed wrist in radial deviation, which is then brought into ulnar deviation. This produces a visual, painful, and characteristic clunk known as the catch-up clunk in patients with midcarpal instability. The “catching up” occurs when the smooth transition during ulnar deviation lags behind until late in ulnar deviation, when the proximal row suddenly clunks into a reduced extended posture.

Brown and Lichtman have suggested dividing the wrist into five zones: three dorsal and two volar. Figure 1-78 shows these five zones and the differential diagnoses that should be considered in each zone. This systematic approach will help to localize the patient’s symptoms and reach an appropriate diagnosis.

FIGURE 1-78

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Operative Techniques Hand and Wrist Surgery