For the resisted tests (Fig. 20.3) the patient’s elbow is kept in extension. This puts more stress on the contractile structures of the wrist and makes it possible to detect even the slightest tendinous and muscular lesions.

Fig 20.3 Resisted movements of the wrist: (a) flexion; (b) extension; (c) radial deviation; (d) ulnar deviation.

Resisted flexion

The patient’s hand is held in the neutral position. The examiner’s contralateral arm is passed under the patient’s in order to hold the patient’s elbow in extension and fixes the forearm with the hand. The other hand is placed under the patient’s hand and creates resistance at the palmar aspect.

This test examines the flexors of the wrist and fingers – the flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis and profundus (Fig. 20.3a).

Resisted extension

Fixation of the patient’s forearm is as in the previous test. The examiner creates resistance at the dorsal aspect of the patient’s hand.

This tests the extensors of the wrist and fingers – the extensor carpi radialis longus, extensor carpi radialis brevis, extensor carpi ulnaris, extensor digitorum communis, extensor indicis proprius and extensor digiti minimi (Fig. 20.3b).

Resisted radial deviation

Resistance is applied at the radial aspect of the patient’s hand – the thumb is not involved – and tests the radial deviators of the wrist – the extensor carpi radialis longus and brevis and flexor carpi radialis (Fig. 20.3c).

Resisted ulnar deviation

Resistance to ulnar deviation is applied at the ulnar aspect of the hand and tests the ulnar deviators of the wrist – the extensor carpi ulnaris and flexor carpi ulnaris (Fig. 20.3d).

The thumb

Passive movement

Backwards movement during extension

The patient flexes the elbow to a right angle and presents the hand with the palm upwards. The examiner takes hold of it with the ipsilateral hand and fixes it. With the other hand the thumb is brought into extension. Then the thumb is moved backwards so as to stretch the anterior part of the capsule of the trapezium–first metacarpal joint (Fig. 20.4).

Fig 20.4 Passive movement of the thumb.

Resisted movements (Fig. 20.5)

Resisted extension

The patient presents the hand with the thumb upwards and it is fixed by the examiner’s contralateral hand. Resistance is then applied with the thumb of the other hand at the dorsal aspect of the distal phalanx. Extension tests the extensors of the thumb – the extensor pollicis longus and extensor pollicis brevis (Fig. 20.5a).

Fig 20.5 Resisted movements of the thumb: (a) extension; (b) flexion; (c) abduction; (d) adduction.

Resisted flexion

Resistance is applied to the palmar aspect of the distal phalanx of the patient’s thumb and tests the flexors of the thumb – the flexor pollicis longus and brevis (Fig. 20.5b).

Resisted abduction

Resistance is applied to the distal part of the first metacarpal bone and tests the abductors of the thumb – the abductor pollicis longus and brevis (Fig. 20.5c).

Resisted adduction

This movement tests the adductor of the thumb – the adductor pollicis (Fig. 20.5d).

The intrinsic muscles of the hand: dorsal and palmar interossei

Squeezing with the index and middle fingers

The patient presents the hand in the horizontal position with the dorsal aspect upwards. The examiner puts an index finger between the patient’s index (II) and middle (III) fingers and asks the patient to squeeze it, so testing the palmar interosseus of the index finger and the dorsal radial interosseus of the middle finger (Fig. 20.6a).

Fig 20.6 Squeezing the fingers: (a) II–III; (b) III–IV; (c) IV–V.

Squeezing with the middle and ring fingers

The examiner’s finger is squeezed between the patient’s middle (III) and ring (IV) fingers. The examiner carries out the test as before, with the finger between the patient’s middle and ring fingers, so testing the dorsal ulnar interosseus of the middle finger and the palmar interosseus of the ring finger (Fig. 20.6b).

Squeezing with the ring and little fingers

The examiner’s finger is squeezed between the patient’s ring (IV) and little (V) fingers. The dorsal interosseus of the ring finger and the palmar interosseus of the little finger are tested (Fig. 20.6c).

Resisted separation of the index and middle fingers

The examiner resists the separation of the patient’s fingers at the distal phalanges, which tests the dorsal interosseus of the index finger and the dorsal ulnar interosseus of the middle finger (Fig. 20.7a).

Fig 20.7 Resisted separation of the fingers: (a) II–III; (b) III–IV; (c) IV–V.

Resisted separation of the middle and ring fingers

This assesses the dorsal radial interosseus of the middle finger and the dorsal interosseus of the ring finger (Fig. 20.7b).

Resisted separation of the ring and little fingers

This tests the palmar interosseus of the ring finger and the abductor of the little finger in the hypothenar, abductor digiti minimi (Fig. 20.7c).

Palpation

Palpation with the joints at rest helps to find the exact localization of lesions in ligaments, tendons or muscles. Palpation is also performed for warmth, swelling and synovial thickening.

Palpation during movement may reveal crepitus. Fine creaking during movement of a tendon in its sheath indicates roughening of the gliding surfaces, the result of overuse. This is quite common in the tendons or muscle bellies of the structures that pass through the first and third tunnels: namely, the abductor and extensors of the wrist. Coarser crepitus can indicate tuberculosis or advanced rheumatoid disease.

Accessory tests

These tests (Fig. 20.8) are not part of the standard examination. They are only done when there is a need for more information about the patient’s problem.