INTRODUCTION

Chronic wrist pain has often been called the lower back pain of hand conditions. Both areas offer the clinician significant diagnostic and therapeutic challenges. As in the examination of the lower back, a precise evaluation based on thorough knowledge of regional anatomy is essential to successful management (Table 6-1).

TABLE 6-1 FOREARM, WRIST, AND HAND CROSS-REFERENCE TABLE BY ASSESSMENT PROCEDURE

The wrist joint is probably the most complicated joint in the body because of its unique arrangement and articulation of the radiocarpal and intercarpal joints. Ligamentous injuries to the carpus can lead to significant and possibly permanent disability. Diagnosis may be difficult with persistent degrees of carpal instability. Definitive treatment modalities have not been perfected. As with most joint injuries, a more thorough understanding of the anatomy and pathogenesis of these injuries is useful (Table 6-2).

TABLE 6-2 PRINCIPAL DIFFERENTIAL DIAGNOSIS LIST FOR WRIST PAIN

Radial side	Tenosynovitis (de Quervain disease)
	Osteoarthritis of first carpometacarpal joint
	Scaphotrapeziotrapezoid osteoarthritis
	Scaphoid non-union
	Ganglion
Dorsal, central	Kienböck disease
	Scapholunate dissociation
	Scapholunate advanced collapse (SLAC wrist)
	Intraosseous ganglion
	Ganglion
Ulnar side	Ulnar abutment syndrome
	Ulnar impaction syndrome
	Distal radioulnar joint degenerative arthritis/instability
	Ulnar head chondromalacia
	Triangular fibrocartilage complex tear
	Extensor carpi ulnaris tendonitis/subluxation
	Lunotriquetral instability
	Pisotriquetral joint disease
	Midcarpal instability

Adapted from Ankarath S: Chronic wrist pain: diagnosis and management, Curr Orthop 20(2):141-151, 2006.

Carpal injuries represent a spectrum of bony and ligamentous damage. The names given to the various injuries describe the resultant damage apparent only on radiographs, for example, lunate dislocation, perilunate dislocation, scaphoid fracture, transscaphoid perilunate fracture-dislocation, and transscaphoid transtriquetral perilunate fracture-dislocation. Each injury is not an entity but part of a continuum.

A stable and pain-free wrist is a prerequisite for normal hand function. In contrast, a painful, unstable, or deformed wrist impairs function. The wrist, a common target of rheumatoid arthritis, is adversely affected by the reaction of synovial tissue on capsuloligamentous structures, articular cartilage, and subchondral bone. The mechanical forces of the different muscle groups acting across the wrist also contribute to deformities.

TABLE 6-3 FOREARM, WRIST, AND HAND CROSS-REFERENCE TABLE BY SYNDROME OR TISSUE

Anterior interosseous syndrome	Pinch grip test
Arterial stenosis	Allen test Tourniquet test

Aseptic necrosis Finsterer sign Carpal fracture

Carpal lift sign

Cascade sign

Finsterer sign

Carpal tunnel syndrome

Phalen sign

Tinel sign at the wrist

Tourniquet test

Wringing test

Colles fracture Maisonneuve sign Denervation

Dellon moving two-point discrimination test

Shrivel test

Weber two-point discrimination test

Digit contractures

Bunnell-Littler test

Test for tight retinacular ligaments

Neuroma Interphalangeal neuroma test Rheumatoid arthritis

Bracelet test

Cascade sign

Sprain Carpal lift sign Tenosynovitis Finkelstein test Ulnar neuropathy

Dellon moving two-point discrimination test

Froment paper sign

Tinel sign at the wrist

Tourniquet test

Wartenberg sign

Weber two-point discrimination test

ORTHOPEDIC GAMUT 6-1 WRIST CARPAL SYSTEM

The nature of injury of the wrist carpal system is determined by:

1. The type of three-dimensional loading

2. The magnitude and direction of the forces involved

3. The position of the hand at the time of impact

4. The biomechanical properties of the bones and ligaments

The initial evaluation of a patient with an injured wrist must be thorough and methodical. In recent years, increased understanding of carpal mechanics and instability patterns, with and without fractures, has increased the importance of accurate examination of the wrist. The diagnosis of sprained wrist is not adequate in establishing a proper treatment regimen. By taking a complete history, performing an exact examination, and using appropriate diagnostic aids such as motion views, tomography, bone scans, and arthrography, the clinician can establish an accurate diagnosis of wrist injury. Only after an accurate diagnosis is established can a rational, therapeutic regimen be prepared.

As with any other orthopedic problem, assessment of wrist and hand disorders begins with a complete history (Box 6-1). Painful disorders of the forearm, wrist, and hand can be classified based on the tissue of origin of pain and its distribution.

ESSENTIAL ANATOMY

The bones of the hand can be divided into four units: a central fixed unit for stability and three mobile units for dexterity and power. The fixed unit is composed of eight carpal bones tightly bound to the second and third metacarpals.

The wrist transmits force between the hand and forearm. Force passes through the capitate bone of the distal carpal row, the scaphoid and lunate bones of the proximal carpal row, and onward proximally to the distal end of the radius. These bones are the ones most likely to be fractured or dislocated in injury of the hand-wrist mechanism. Of the two long bones of the forearm, only the radius has true articulation with the carpal bones. The carpal fractures often involve the scaphoid. Scaphoid fractures, with typical tenderness at the anatomic snuffbox, can result in chronic wrist pain because of non-union or collapse of the structure following injury. Wrist radiocarpal trauma can also involve the triangular fibrocartilage complex (Table 6-4).

TABLE 6-4 TRIANGULAR FIBROCARTILAGE COMPLEX INJURY CLASSIFICATION

Class II: Degenerative (ulnocarpal abutment syndrome)

A. Triangular fibrocartilage complex wear

B. Triangular fibrocartilage complex wear—with lunate or ulnar chondromalacia

C. Triangular fibrocartilage complex perforation—with lunate or ulnar chondromalacia

D. Triangular fibrocartilage complex perforation

a. With lunate or ulnar chondromalacia

b. With lunotriquetral ligament perforation

E. Triangular fibrocartilage complex perforation

a. With lunate or ulnar chondromalacia

b. With lunotriquetral ligament perforation

c. With ulnocarpal arthritis

ORTHOPEDIC GAMUT 6-2 MOBILE UNITS OF THE WRIST

The three mobile units projecting from the fixed unit of the wrist are:

1. The thumb, for powerful pinch and grasp and fine manipulations

2. The index finger, for precise movements alone or with the thumb

3. The middle, ring, and little fingers, for power grip

ORTHOPEDIC GAMUT 6-3 RADIOCARPAL JOINT

The radiocarpal joint consists of the following:

1. The distal surface of the radius

2. The scaphoid and lunate bones

3. The triangular fibrocartilage connecting the medial side of the distal radius with the ulnar styloid process

4. The triquetrum

ESSENTIAL MOTION ASSESSMENT

Movements of the wrist comprise flexion, extension, and ulnar and radial deviation. Flexion-extension movements of the fingers occur at both the metacarpophalangeal (MCP) and the interphalangeal joints (Fig. 6-1).

FIG. 6-1 Examples of thumb movements. A, Flexion-extension. B, Abduction-adduction. C, Opposition.

Movements of the thumb are described in terms different from those applied to the other digits because the thumb is positioned in a way that is different from the way the fingers are positioned, and the thumb is capable of unique movements not possible in the other digits.

Opposition is a unique capability, possessed only by the thumb. The goal of opposition is to cause the pulp surface (i.e., the rounded eminence directly opposite the nail) of the distal phalanx to face the pulp surfaces of the other digits. This capability is essential to realizing the full range of capabilities for grasping and manipulating objects with the hand.

Creating a cup-shaped recess in the palm of the hand requires movement of the other four digits. This recess allows an object to be cradled in the palm before the fingers are closed over it.

For examination of the wrist-hand range of motion, the middle finger is considered midline (Fig. 6-2). Wrist flexion decreases as the fingers are flexed. Movements of flexion and extension are ultimately limited by muscles and ligaments (Figs. 6-3 and 6-4).

FIG. 6-2 Range of motion of the hand and wrist.

FIG. 6-3 The wrist in a neutral position. Radial deviation of 15 degrees or less and ulnar deviation of 30 degrees or less.

FIG. 6-4 A, The wrist in a neutral position. B, Wrist flexion. C, Wrist extension (dorsiflexion).

Finger abduction is 20 to 30 degrees at the MCP joints. Finger adduction is 0 degrees at the same joint. The loss of finger abduction or adduction has minimal effect on the activities of daily living. Thumb flexion at the carpometacarpal joint is in a range of 45 to 50 degrees. At the MCP joint, the range is 50 to 55 degrees. At the interphalangeal joint, thumb flexion is in a range of 80 to 90 degrees. Extension of the thumb at the interphalangeal joint is 0 to 5 degrees. Thumb abduction is 60 to 70 degrees. Thumb adduction is 30 degrees. Seventy degrees or less of retained flexion of the thumb at the interphalangeal joint and 50 degrees or less retained flexion at the MCP joint are considered impairments of the thumb in the activities of daily living. Zero degrees of extension at the interphalangeal joint is considered the sole impairment of extension for the thumb. Forty degrees or less of radial abduction and 25 degrees or less of adduction are considered impairments of the thumb in the activities of daily living (Fig. 6-5).

FIG. 6-5 Finger flexion (A) at the MCP joints. Extension (B) at the MCP joints. Retained active finger flexion of 80 degrees or less at the MCP joint, 90 degrees or less at the proximal interphalangeal joint, and 60 degrees or less at the distal interphalangeal joint serve as an impairment of the fingers in the activities of daily living. Retained active extension of 10 degrees or less at the MCP joint serves as the sole impairment of the fingers in the activities of daily living.

ESSENTIAL MUSCLE FUNCTION ASSESSMENT

ORTHOPEDIC GAMUT 6-4 MUSCLES OF THE HAND

Muscles controlling movements of the hand are divided into two groups:

1. Extrinsic muscles that originate within the arm and forearm

2. Intrinsic muscles, the origins and insertions of which are entirely within the hand (Figs. 6-6 to 6-10)

FIG. 6-6 Flexion. The patient flexes the wrist against graded resistance provided by the fingertips of the examiner’s other hand placed in the patient’s palm.

FIG. 6-7 Extension. The patient extends the wrist against graded resistance applied by the examiner’s other hand to the dorsal surface of the patient’s metacarpals.

FIG. 6-8 Flexion of the interphalangeal joints of the fingers is accomplished by the long flexor tendons.

FIG. 6-9 The intrinsic muscles of the hand consist of a central group containing the interossei and lumbricales and the two lateral groups of hypothenar and thenar eminences.

FIG. 6-10 The interosseous and lumbrical muscles are of fundamental importance in the extension of the fingers.

ESSENTIAL IMAGING

The importance of routine posteroanterior and lateral radiographs in neutral position of the wrist cannot be overemphasized.

ORTHOPEDIC GAMUT 6-5 SCAPHOLUNATE ADVANCE COLLAPSE (SLAC) WRIST GRADING BASED ON THE EXTENT OF THE DEGENERATIVE CHANGES

Stage 1a: Degenerative changes between the scaphoid and the radial styloid

Stage 1b: Degenerative changes involving the whole of the radioscaphoid joint

Stage 2: Degenerative arthritis involving the scaphocapitate (midcarpal) joint

ALLEN TEST

Assessment for Peripheral Vascular Obstruction at the Wrist

ORTHOPEDIC GAMUT 6-6 REFLEX SYMPATHETIC DYSTROPHY–COMPLEX REGIONAL PAIN SYNDROME (RSD-CRPS) LIMB PROTECTION

Three stages of RSD-CRPS limb protection by the patient are:

1. Not allowing palpation or percussion or even light touch of the affected tissue

2. Loss of use, stiffness of soft tissues, loss of joint motion, development of contracture, and atrophy of skin; warmth of hypervascularity turns to coldness; strength and function diminish further

3. Shiny, dry skin; degeneration of muscle tone; further joint stiffness; and both joint and muscle contracture

Comment

Diagnosis of reflex sympathetic dystrophy–complex regional pain syndrome (RSD-CRPS) is initially based on clinical symptoms and signs for the upper extremity, which includes painful disuse of the hand and wrist with a high degree of awareness. Supportive laboratory testing includes positive bone scans, hypervascularity (thermography), and positive sweat test with autonomic dysfunction and quantitative sudomotor axon reflex test. Later, osteoporosis can help confirm the diagnosis. The sympathetic dystrophy scale is effective in confirming and rating the severity of this syndrome (Boxes 6-2 and 6-3).

BOX 6-3 CLASSIFICATION OF COMPLEX REGIONAL PAIN SYNDROME (CRPS)—MAJOR CATEGORIES

Adapted from Manning DC: Reflex sympathetic dystrophy, sympathetically maintained pain, and complex regional pain syndrome: diagnoses of inclusion, exclusion, or confusion? J Hand Ther 13(4):260-268, 2000.

I. Sympathetically maintained pain syndrome (type I and type II)

II. Sympathetically independent pain syndrome (type III)

A. Category I

• Type I (reflex sympathetic dystrophy) usually follows an initiating noxious event

• Continuous pain or allodynia and hyperpathia is not limited to the territory of a single peripheral nerve.

• Disproportionate pain to the inciting event

• Edema, skin blood flow abnormality

• Abnormal sudomotor activity

• Motor dysfunction disproportionate to the inciting event

• Diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction.

• Type II (major causalgia)

• Major nerve injury, more regionally confined presentation (usually), principally involving the territory of the involved nerve

• Spontaneous pain or allodynia and hyperpathia is usually limited to the area involved but may spread distally or proximally.

• Edema, blood flow abnormality

• Abnormal pseudomotor activity is or has been shown in the region of pain subsequent to the inciting event.

• Motor dysfunction disproportionate to the inciting event

• Diagnosis is excluded by conditions that otherwise account for the degree of pain and dysfunction.

B. Category II

• Type III CRPS (sympathetically independent pain)

• Disproportionate pain and sensory change, with motor and tissue change that do not respond to sympathetic block

ORTHOPEDIC GAMUT 6-7 PULSES IN THE WRIST

Pulses are palpated at the wrist in three places:

1. The radial artery lying just medial to the radial styloid process, which passes toward the hand

2. The ulnar artery, which passes just lateral (in the anatomic position) to the pisiform bone

3. The deep radial artery, which crosses the floor of the anatomic snuffbox

PROCEDURE

• The patient is seated and instructed to make a tight fist to express blood from the palm. The examiner uses finger pressure to occlude the radial and ulnar arteries.

• The patient opens and closes the fist to express any remaining blood. The examiner releases the arteries one at a time (Fig. 6-11).

• The sign is negative if the pale skin of the palm flushes immediately after an artery is released.

• The sign is positive if the skin of the palm remains blanched for more than 5 seconds. This test, which should be performed before Wright test, Eden test, and the shoulder hyperabduction maneuver, is significant for revealing vascular occlusion of the artery tested.

FIG. 6-11

CLINICAL PEARL

This test will often elicit paresthesia when an underlying distal peripheral nerve entrapment syndrome exists (carpal tunnel syndrome). The test is used as an early indicator of other general pathologic conditions only when paresthesia is elicited.

BRACELET TEST

Assessment for Degenerative Changes of the Wrist Articulations (Rheumatoid Arthritis)

ORTHOPEDIC GAMUT 6-8 RHEUMATOID DEFORMITY

Rheumatoid Deformity of the Wrist is Usually Characterized by:

1. Dorsal, distal, and then ulnar displacement of the distal ulna (caput ulnae syndrome)

2. Subluxation of the carpus, usually palmarly with supination and radial deviation leading to a zigzag collapse of the wrist and secondary increased ulnar drift

3. Foreshortening and widening of the carpus

4. End-point deformities in which the patient exhibits subluxation, dislocation, or ankylosis of the wrist

5. Digit stance deformities, particularly extension or flexion stance alterations during cascade testing

6. Signs of neurovascular alterations

ORTHOPEDIC GAMUT 6-9 FINDINGS THAT SUGGEST, BUT ARE NOT PATHOGNOMONIC OF, RHEUMATOID ARTHRITIS

• Symmetric swelling of the proximal interphalangeal (PIP) joints

• Boutonnière or swan-neck deformities of several PIP joints

• Swelling or tenderness of the MCP joints

• Ulnar deviation or subluxation of these MCP and PIP joints

• Synovitis of the wrist (especially at the distal ulna)

• Tenderness of the distal ulna

• Swelling of the extensor carpi ulnaris tendon

ORTHOPEDIC GAMUT 6-10 MORE THAN ONE OF THESE MAKES RHEUMATOID ARTHRITIS A LIKELY DIAGNOSIS

• The symptom complex of MCP joint swelling with ulnar deviation of the fingers is present.

• Dorsal interosseous muscle atrophy and extensor swelling at the wrist is virtually pathognomonic of rheumatoid arthritis.

• Caput ulnae syndrome also has a high degree of specificity.

• Subcutaneous nodules in the elbow and forearm may point to early diagnosis of this syndrome.

• The skin is moist, warm, lightly mottled, and thin and may be transparent.

• The erythrocyte sedimentation rate is elevated, but a normal value does not rule out the disease.

PROCEDURE

• The examiner gives mild-to-moderate lateral compression of the lower ends of the radius and ulna.

• This compression causes acute forearm, wrist, and hand pain (Fig. 6-12).

• The test is significant for rheumatoid arthritis.

FIG. 6-12

CLINICAL PEARL

The bracelet test can be similar to a manual tourniquet test. The examiner must carefully compress osseous structures and must avoid occluding arterial structures.

BUNNEL-LITTLER TEST

PROCEDURE

• The examiner slightly extends the MCP joint while moving the proximal interphalangeal (PIP) joint into flexion.

• A PIP joint that cannot be flexed indicates a tight intrinsic muscle or contracture of the joint capsule, which is a positive finding.

• This joint will not flex fully if the capsule is tight (Fig. 6-13).

FIG. 6-13

CARPAL LIFT SIGN

Assessment for Carpal Fracture or Sprain

PROCEDURE

• While fixing the other fingers to the examination table, the examiner applies pressure to the dorsum of the digit being examined.

• The patient attempts to lift or extend the finger off the table (Fig. 6-14).

• The sign is present if this action causes pain at the dorsum of the wrist.

• The presence of this sign indicates carpal fracture or sprain.

FIG. 6-14

CLINICAL PEARL

Carpal lift is accomplished when the finger is extended against resistance. The earliest sign of carpal fracture or degeneration, before using imaging, is the pain elicited with this test. With a carpal fracture, the carpal lift activity shifts bony fragments and produces the corresponding discomfort.

CASCADE SIGN

Assessment for Internal Derangement of Carpometacarpal Articulations and Internal Derangement of Phalanges

PROCEDURE

• The patient is seated, elbow flexed, and forearm supinated. The patient flexes the fingers at the MCP and PIP joints, as if the hand is gripping a golf club. A complete fist should not be made.

• In the normal hand, the longitudinal axis of the four fingers converges over or near the scaphoid tubercle.

• The sign is present if any of the fingers are askew, which indicates internal derangement of the metacarpals, carpals, or both (Fig. 6-15).

FIG. 6-15

CLINICAL PEARL

A faulty cascade of the fingers, indicating internal derangement of the wrist and hand, is an impediment of the hand grasp in daily activities. Patients usually have adopted accommodating grips. Pain or grip weakness is what precipitates the need for professional care.

DELLON MOVING TWO-POINT DISCRIMINATION TEST

Assessment for Dermatome Sensory Disturbances

ORTHOPEDIC GAMUT 6-12 TWO-POINT DISCRIMINATION

The normal threshold for two-point discrimination distance for the volar surface of the hand varies according to the zone being tested:

1. Between the fingertip and the DIP joint, two-point discrimination is normal from 3 to 5 mm, diminished if 6 to 10 mm, and absent if greater than 10 mm.

2. Between the DIP joint and the PIP joint, normal is 3 to 6 mm, diminished is 7 to 10 mm, and absent is greater than 10 mm.

3. Between the PIP joint and the finger web, normal is 4 to 7 mm, diminished is 9 to 10 mm, and absent is greater than 10 mm.

4. Between the web and the distal palmar crease, normal is 5 to 8 mm, diminished is 9 to 20 mm, and absent is greater than 20 mm.

5. Between the distal crease and the central palm, normal is 6 to 9 mm, diminished is 10 to 20 mm, and absent is greater than 20 mm.

6. At the base of the palm and wrist, normal is 7 to 10 mm, diminished is 11 to 20 mm, and absent is greater than 20 mm.

7. The threshold for the dorsal surface is higher in all zones: normal is 7 to 12 mm, diminished is 13 to 20 mm, and absent is greater than 20 mm.

8. Below the elbow but above the wrist, normal is 40 to 50 mm, diminished is between 55 and 80 mm, and absent is greater than 80 mm.

9. Above the elbow, normal is 65 to 75 mm, diminished is between 80 and 100 mm, and absent is greater than 100 mm.

PROCEDURE

• Two blunt points are moved proximally and distally in the long axis of the digit.

• One or two points of the Boley gauge are randomly used.

• The distance between the two points is decreased until the two points can no longer be distinguished (Fig. 6-16).

• The object is to determine whether the patient can discriminate between being touched with one or two points and the minimal distance at which two points touching the skin are recognized.

• Several areas on the uninvolved hand should be checked because some patients have congenitally abnormal two-point discrimination.

FIG. 6-16

CLINICAL PEARL

A Janet test can be performed simultaneously with Dellon test. If the patient’s responses are bizarre and do not follow anatomic distributions, psychogenic anesthesia is suspected. The patient is instructed to say yes when the stimulus is felt and no when the stimulus is not felt. The patient will say no if functional anesthesia exists.

FINKELSTEIN TEST

Assessment for de Quervain Disease (Hoffman Disease, Tenosynovitis of the Thumb)

PROCEDURE

• The patient makes a fist with the thumb inside the fingers. The examiner deviates the wrist in an ulnar direction.

• If this action produces pain over the abductor pollicis longus and the extensor pollicis brevis tendons at the wrist, the test is positive (Fig. 6-17).

• Pain indicates tenosynovitis in these two tendons.

FIG. 6-17

CLINICAL PEARL

Finkelstein test produces an exquisitely painful response when stenosing tenosynovitis is present. Initially, determining the severity of the condition is somewhat easier when the patient actively tucks the thumb in and then deviates the hand and wrist in an ulnar direction. Depending on the response this produces, the passive test can then be performed. The pain elicited by this test is discrete and can be long lasting once excited.

FINSTERER SIGN

PROCEDURE

• The sign is present when grasping an object hard, clenching the hand, or making a fist fails to show the normal prominence of the third metacarpal on the dorsal surface and when percussion of the third metacarpal elicits tenderness just distal to the center of the wrist joint (Fig. 6-18).

• The test is significant for Kienböck disease (aseptic necrosis of the lunate).

FIG. 6-18

CLINICAL PEARL

For this sign, all the metacarpal heads are percussed. This gross, low-frequency vibration will localize any cortical defect. In addition, an important point to remember is that ganglions are the most common soft tissue swellings of the wrist region. They are usually outpouchings of the capsule from the carpal joints, but they may also arise in relation to the tendons. The most common site of origin is from the scapholunate joint. In nearly every instance, a connection to the underlying joint or tendon sheath exists. Patients often have a painless swelling but, in some cases, may complain only of wrist pain, with no visible swelling. This scenario is particularly likely in early stages when the ganglion is small and not visible.

FROMENT PAPER SIGN ALSO KNOWN AS FROMENT SIGN

Assessment for Ulnar Nerve Palsy

PROCEDURE

• The patient grasps a piece of paper between any two fingers (Fig. 6-19).

• Failure to maintain the grip when the paper is pulled away indicates ulnar nerve paralysis (Fig. 6-20).

• This result indicates a positive test.

• The test indicates ulnar nerve paralysis.

FIG. 6-19

FIG. 6-20 In a modification of the Froment paper test, the patient adducts and flexes the tip of the finger to the tip of the thumb. The examiner tries to pull the digits apart. Failure of the fingers to maintain sufficient strength to resist this motion suggests ulnar nerve paralysis. (Anterior interosseous nerve lesions must be differentiated by electromyogram.)

CLINICAL PEARL

A change from a tip-to-tip pinch grip position to a pulpto-pulp position is the earliest sign of ulnar entrapment (anterior interosseous nerve lesions must be differentiated). An electromyogram requires more gross muscle deficiency for conclusive findings, and the nerve conduction velocity may be equivocal in the early stages of nerve degeneration.

INTERPHALANGEAL NEUROMA TEST

Assessment for Interdigital Neuroma

PROCEDURE

• Neuromas should be carefully sought out by examination of the area using a slender instrument for palpating, such as the blunt end of a reflex hammer (Fig. 6-21).

• A localized spot in a scar will cause severe pain and is associated with paresthesia.

• The neuroma itself may be felt as a discrete mass.

FIG. 6-21

CLINICAL PEARL

Although neuromas in continuity develop more frequently in the lower extremity and near amputations, they do develop elsewhere. Neuromas in continuity are observed at the bifurcation of nerve branches near the base of digits and may result from the chronic mechanical irritation caused by malalignment of the digit structures.

MAISONNEUVE SIGN

Assessment for Colles Fracture

ORTHOPEDIC GAMUT 6-14 COLLES FRACTURE

Poor results from Colles fracture are caused by:

1. Residual dorsal tilt more than 20 degrees (normal, 11 to 12 degrees of volar tilt)

2. Radial inclination more than 10 degrees (normal, 22 to 23 degrees)

3. Articular incongruity more than 2 mm

4. Radial translation more than 2 mm

PROCEDURE

• A positive Maisonneuve sign is characterized by marked hyperextensibility (dorsiflexion) of the hand (Fig. 6-22).

• The sign is present in Colles fracture.

FIG. 6-22

CLINICAL PEARL

Maisonneuve sign remains a finding long after the fracture healing process is completed. A marked hyperextension of the wrist, with or without complaint, warrants imaging.

PHALEN SIGN ALSO KNOWN AS PHALEN SIGN AND PRAYER SIGN

Assessment for Carpal Tunnel Syndrome (Median Nerve Palsy)

PROCEDURE

• The patient’s wrists are flexed maximally. The position is held for up to 1 minute as the dorsums are pushed together (Fig. 6-23).

• Tingling sensations that radiate into the thumb, the index finger, and the middle and lateral half of the ring finger are a positive sign.

• A positive sign indicates carpal tunnel syndrome (CTS) caused by median nerve compression (Fig. 6-24).

FIG. 6-23

FIG. 6-24

CLINICAL PEARL

Phalen sign duplicates the wrist flexion-extension maneuvers that irritate the median nerve. The presence of Phalen sign is a good indicator that wrist splints will be useful in the management of CTS. As a screening test, a reverse Phalen maneuver can be performed. The patient is asked to press the hands together in the vertical plane and raise the elbows until they are horizontal. Loss of any dorsiflexion should be obvious. The most common cause of lost dorsiflexion is stiffness after a Colles fracture.

PINCH GRIP TEST

PROCEDURE

• The patient pinches the tips of the index finger and thumb together in tip-to-tip pinch (Fig. 6-25).

• If the patient is unable to pinch tip to tip and has a pulp-to-pulp pinch of the index finger and thumb, the sign for anterior interosseous nerve syndrome is positive (Fig. 6-26).

• This sign may indicate entrapment of the anterior interosseous nerve.

FIG. 6-25

FIG. 6-26

CLINICAL PEARL

Even minor irritation of the anterior interosseous nerve produces this sign. The inability to pinch grip tip to tip influences the patient’s ability to pick up small objects, which is the dysfunction that usually causes the patient to seek professional care.

SHRIVEL TEST (ALSO KNOWN AS O’RIAIN SIGN)

Assessment for Peripheral Nerve Denervation

PROCEDURE

• The affected fingers are placed in warm (40° C) water for approximately 30 minutes (Fig. 6-27).

• The fingers are removed from the water and skin wrinkling is observed, especially over the finger pulp.

• Normal fingers wrinkle; denervated fingers do not.

• O’Riain sign is valid only in the first 90 to 120 days after injury, consistent with reactions of degeneration.

FIG. 6-27

CLINICAL PEARL

Muscle wasting in CTS is a good illustration of the trophic relationship that exists between striated muscle and the nerves that innervate them. When the nerve input to such a muscle is interrupted, the muscle wastes away, loses its strength, and eventually becomes much reduced in size. Even when the nerve-muscle relationship remains intact, if physiologic transmission of impulses is blocked, the muscle similarly wastes away. Smooth muscle is innervated by autonomic nerves, but no such trophic relationship exists in the case of smooth muscle.

TEST FOR TIGHT RETINACULAR LIGAMENTS

Assessment for Fixation of Phalangeal Retinacular Ligaments

ORTHOPEDIC GAMUT 6-17 PROXIMAL INTERPHALANGEAL DISLOCATIONS

Acute dorsal proximal interphalangeal dislocation categories:

I. Hyperextension: joint surfaces in contact

II. Dorsal dislocation: with dorsal dislocation of the middle phalanx on the proximal phalanx (bayonet)

III. Proximal dislocation: fracture of the volar base of the middle phalanx

PROCEDURE

• The PIP joint is placed in a neutral position as the distal interphalangeal (DIP) joint is flexed passively (Fig. 6-28).

• If the DIP joint does not flex, the ligaments or capsule are tight or contracted.

• If the PIP joint flexes easily, the retinacular ligaments are tight but the capsule is normal.

FIG. 6-28

TINEL SIGN AT THE WRIST (ALSO KNOWN AS FORMICATION SIGN, DISTAL TINGLING ON PERCUSSION [DTP] SIGN, AND HOFFMAN-TINEL SIGN)

Assessment for Peripheral Neuropathy in Median or Ulnar Nerve Distribution

ORTHOPEDIC GAMUT 6-18 FIVE PATTERNS OF ULNAR NEUROPATHY DEPENDING ON THE SITE OF THE LESION

• Type I lesion

• Either outside or just within the proximal end of Guyon canal.

• Affects the mixed ulnar nerve.

• All of the hand intrinsic muscles and sensation of the medial 1.5 digits are affected.

• Dorsal ulnar cutaneous sensory branch distribution is spared.

• Type II lesion

• Located within Guyon canal and affects only the superficial sensory branch.

• Creates a pure sensory neuropathy of the medial 1.5 digits.

• Type III lesion

• Involves the deep motor branch distal to its bifurcation from the superficial sensory nerve but proximal to the motor branch to the hypothenar compartment.

• Results in a pure motor neuropathy affecting all the hand intrinsics, including the hypothenar muscles.

• Type IV lesion

• Occurs on the deep motor branch distal to the hypothenar branch; preserves hypothenar function.

• Affects other ulnar-innervated hand intrinsics.

• Type V lesion

• Occurs just proximal to the branches supplying the first dorsal interosseous and adductor pollicis muscles; results in decreased activity of these muscle groups only.

PROCEDURE

• The carpal tunnel is percussed at the wrist (Fig. 6-29).

• Tingling in the thumb, index finger, forefinger, and the middle and lateral half of the ring finger is a positive finding.

• Tingling and paresthesia must be felt distal to the point of percussion for a positive finding.

• The test can demonstrate the rate of regeneration of the sensory fibers.

• The most distal point of the abnormal sensation represents the distal limit of nerve regeneration.

FIG. 6-29

CLINICAL PEARL

Tinel sign is extremely useful in identifying (1) the most proximal point of nerve regeneration or (2) the most distal point of nerve degeneration. These points are one and the same. Tinel sign is most evidenced at the Valleix points (tender points) along the course of the peripheral nerve (as in a neuralgia or neuritis). The examiner also may slide the tip of the index finger across the palm, noting frictional resistance and temperature. Increased thenar resistance from lack of sweating and temperature rise (vasodilation) may occur with median involvement.

TOURNIQUET TEST

Assessment for Neural Irritability as a Result of Posterior Interosseous or Median Nerve Compression

ORTHOPEDIC GAMUT 6-19 TWO TYPES OF POSSIBLE GANGLION CYST

Type I: An expanding cyst in the nerve trunk leaving the epineurium intact

Type II: An expanding cyst that penetrates the epineurium.

Comment

Significant diminution of blood flow to individual digits or to an entire hand results in pale nail beds, slow capillary recovery after skin compression, diminished bleeding after skin puncture, lowering of the skin temperature, and pain of varying intensity. Symptoms and signs of pain, pulselessness, pallor, paresthesia, and paralysis indicate arterial insufficiency or inadequate capillary perfusion (Table 6-5). The coexistence of pallor with cyanosis and rubor is consistent with vasoconstriction and subsequent vasodilation. This sign may occur in the presence of posterior interosseous nerve compression.

TABLE 6-5 BLOND MCINDOE COLD INTOLERANCE SYMPTOM SEVERITY (CISS) QUESTIONNAIRE

Question	Score
1. Which of the following symptoms of cold intolerance do you experience in your injured limb on exposure to cold?	Not scored
Please give each symptom a score between 0 and 10, where 0 = no symptoms at all and 10 = the most severe symptoms imaginable.
Pain, numbness, stiffness, weakness, aching, swelling, skin color change (white/bluish white/blue)
2. How often do you experience these symptoms? (Please check.)
Continuously, all the time	10
Several times a day	8
Once a day	6
Once a week	4
Once a month or less	2
3. When you develop cold induced symptoms, on your return to a warm environment are the symptoms relieved? (Please check.)
Within a few minutes	2
Within 30 minutes	6
After more than 30 minutes	10
4. What do you do to ease or prevent your symptoms occurring? (Please check.)
Take no special action	0
Keep hand in pocket	2
Wear gloves in cold weather	4
Wear gloves all the time	6
Avoid cold weather, stay indoors	8
Other (please specify)	10
5. How much does cold bother your injured hand in the following situations? (Please score 0–10.)
Holding a glass of ice water	10
Holding a frozen package from the freezer	10
Washing in cold water	10
When you get out of a hot bath or shower with air at room temperature	10
During cold wintry weather	10
6. Please state how each of the following activities have been affected as a consequence of cold induced symptoms in your injured hand and score each. (Please score 0–4.)
Domestic chores	0 1 2 3 4
Hobbies and interests	0 1 2 3 4
Dressing and undressing	0 1 2 3 4
Tying your shoelaces	0 1 2 3 4
Your job	0 1 2 3 4

However, the scores given in question #1 do not count; overall, minimal score of 4 and a maximal score of 100. A score of 30 is the cut-off point for abnormal cold intolerance. Numbness is the most frequent cold-induced symptom, present in 80% of the time. Other symptoms of frequency are stiffness (77%), weakness (72%), aching (67%), pain (63%), skin color change (50%) and swelling (33%).

From Irwin MS et al: Cold intolerance following peripheral nerve injury. Natural history and factors predicting severity of symptoms, J Hand Surg 22B(3):308-316, 1997.

PROCEDURE

• Application of a pneumatic tourniquet to a normal extremity with pressure elevated to 20 mm Hg above the patient’s resting diastolic blood pressure will obliterate arterial inflow and venous outflow; slow motor nerve conduction, decrease sensory conduction, and cause severe pain in the hand and forearm, all of which occur at the site of tourniquet compression.

• Anoxia and nerve compression occur simultaneously, and muscle weakness is evident within 3 to 5 minutes.

• Digital paresthesia occurs, and sensation diminishes gradually to anesthesia in approximately 30 minutes.

• These painful sensations are a combination of muscle and nerve ischemia and nerve compression.

• The appearance of symptoms at less than 20 mm Hg above the patient’s resting diastolic blood pressure or sooner than 3 to 5 minutes is a positive test result.

• A positive test indicates neural instability as a result of posterior interosseous nerve or median nerve compression syndromes (Fig. 6-30).

FIG. 6-30

WARTENBERG SIGN

Assessment for Ulnar Palsy

PROCEDURE

• The patient performs a hard grasp strength test with a dynamometer.

• The examiner observes the position and function of the digits in the action.

• If the position of abduction is assumed by the little finger, the sign is present (Fig. 6-31).

• The sign is present in ulnar palsy.

FIG. 6-31

WEBER TWO-POINT DISCRIMINATION TEST

Assessment for Diminished Peripheral Nerve Sensibility

ORTHOPEDIC GAMUT 6-20 TACTILE DISCRIMINATION

Four types of tactile discrimination are:

1. Stereognosis

2. Graphesthesia

3. Extinction

4. Two-point discrimination

ORTHOPEDIC GAMUT 6-21 QUALITIES OF SENSIBILITY

Five elementary qualities of sensibility evoked by stimulation via:

5. Movement and position

ORTHOPEDIC GAMUT 6-22 NEURAL SENSORY UNIT

Factors influencing the neural sensory unit:

1. The diameter of the first-order afferent neuron

2. The properties of the sensory receptors

3. The size and population of the receptive field

4. The threshold for the entire sensory unit

Comment

Ten zones in the hand are tested, six in the territory of the median nerve and four in the territory of the ulnar nerve. The scores are interpreted as suggested by Imai and colleagues (Table 6-6). A score of 6.10 is interpreted as having no sensation.

TABLE 6-6 IMAI CLASSIFICATION OF SENSORY RECOVERY

Quality of Sensation (Range 1–5)	Filament Marking
1. Normal	2.83
2. Diminished light touch	3.61
3. Diminished protective sensation	4.31
4. Loss of protective sensation	4.56
5. Anesthetic	6.10

From Imai H, Tajima T, Natsuma Y: Interpretation of cutaneous pressure threshold (Semmes-Weinstein monofilament measurement) after median nerve repair and sensory reeducation in the adult, Microsurgery 10(2):142-144, 1989.