Keywords: Hand assessmemt, Subjective Ax, objective Ax, Passive ROM, Active ROM, Wrist pain, Strength Tests, Dequervains, Differential Diagnosis, Red flags.
Wrist and Hand physiotherapy assessment
The Wrist and Hand Assessment is vital in the diagnosis of distal upper limb pain. It should include a full subjective and objective examination with use of special tests to aid differential diagnosis. The best way to learn good assessment skills is through hands on practice and watching experts. Try to spend a day with a consultant or extended scope practitioner to see how they perform an assessment. Visit the student room to find preparation notes for work experience days.
The subjective examination aims to gain valuable information on how the symptoms have come about and what is causing them.
- Patient history ( dominant hand/ functional limitations)
- Social history
- Insidious onset?
- Region – identify possible structures being affected.
- Are symptoms felt within a dermatomal pattern?
- Is the pain/symptoms in particular fingers? (Click here to see which nerves supply which fingers)
What does this tell you?
The wrist and hand are made up of bones, tendons, muscles, ligaments and other soft tissue. It is important to undertake a thorough subjective assessment to provide clues to the structures involved. When examining the wrist and hand you must consider places that can refer to this area to rule out whether the source of the pain is truely coming from structures within or around the hand. Key details in aiding differential diagnosis include the presents of pins and needles (usually representative of neural involvement), mechanism of injury (Did the patient receive trauma to local area (hand – this may suggest local damage) or the head/neck (neural referral)? Do they have poor posture- could this be compressing on neural structures? Do they have a manual job which requires heavy/repetitive movements? Our hands allow us to create fine movement and our essential to carrying out every day tasks. This is a good time to begin considering goals for the patient. For example be able to ‘Hold fork for one minute whilst eating.’ it is the physiotherapists job to break this goal down to make it achievable and tailor your treatment.
TASK: Bullet point a break down of this goal and what treatments you could employ?
Click here for answer
The objective examination gives you quantifiable measures to rule out what structures are involved and to reassess after treatment to determine improvement/deterioration. Clinical reasoning – The hand can be the referral site for pain in the cervical spine, shoulder or elbow therefore these joints must be ruled out before proceeding.
- Observation – Posture, Bony deformity, Muscle atrophy.
- AROM Wrist flex (70-800), wrist ext (65-800), Wrist radial (15-250), Wrist ulnar deviation (30-400), Digits Flex/ext, opposition.
- Grip strength
- Pinch strength
- Reflexes : Biceps(C5), Triceps(C7), Brachioradalis (C6)
- Joint end feel.
Active Range of Movement
- Carpal Tunnel
- Phalens test – Detects carpal tunnel syndrome. Position – Elbows on table. Full flexion of both wrists for one minute. A positive sign would be reproduction of symptoms (tingling in median nerve distribution). Another method is to ask the patient to place the dorsal aspects of their hands together with full flexion.
- Wrist flexion and Median nerve compression tests – Position : extended elbow, forearm supination, wrist flexion to 600. Clinician then median nerve with finger over the median nerve a the carpal tunnel. The position is held for 20 seconds. A positive sign would be reproduction of symptoms (Paraesthesia in thumb, index finger, middle finger.
- Tinel’s Sign – (detects regeration rate of sensory fibers of the ulnar nerve.) Clinician taps area of patients ulnar nerve groove behind medial epicondyle.
- Positive sign = Tingling sensation or pins and needles in ulnar nerve distribution.
- Wartenberg’s Sign (Detects ulnar neuritis). Position: patient rests hands on table. Clinician passively spreads patients fingers. Pt asked to adduct fingers. Positive sign = Unable to adduct 5th digit to others.
- Foments Sign – Detects ulnar nerve paralysis. Position: Patient attempts to hold piece of paper between finer and thumb. Clinician tries to pull paper out. Flexion of the distal phalanx of the thumb due to weakness of the adductor policis due to paralysis would indicate a positive sign.
- 2 point discrimination test – Detects decreased hand sensation. Using two stimuli apply simultaneously to hand. The inability to distinguish 2 points greater than 6mm apart would indicate reduced hand sensation.
- Finkelsteins Test – Detects Tenosynovitis in the thumb (APL and EPL) in Dequervains syndrome. Patient holds thumb beneath flexed fingers. UD is applied. Positive Sign : Reproduction of symptoms.
- Brunnel-Littler test – Detects tight intrinsic muscles from PIP joint capsular tightness. Patient holds MCP joint slight extended which clinician moves PIP into flex (if possible). Positive sign– PIP unable to flex unless MCP is slightly flexed. If movement is blocked with MCP in neutral or flexed then this may be due to tight joint capsule rather than tight intrinsic muscles.
- Tightness of the retinaculum- Used to differentiate between tight retinaculum ligaments and from capsular tightness. Clinician holds PIP joint in neutral while flexing the DIP joint. Positive Sign – Patient unable to flex DIP joint. If PIP joint is then flexed and DIP flexes easily this is due to tight retinaculum ligaments. If the DIP is unable to flex in both positions then the tightness is due to tight capsule.
- Valgus and Varus stress test – Tests stability of collateral ligaments of the digit. Used to identify game keepers/skiers thumb. Clinician stabilizes test finger and applies valgus/varus forces at MCP, PIP, DIP joint comparing laxity with the uninvolved side.
- Allen’s Test- Detects occlusion of the ulnar/radial artery.
- TFCC load test – Detects ulnocarpal impingement and TFCC tears. Clinician ulnarly deviateswrist whil manipulating the proximal carpal bones. Positive sign – Crepitus, clicking/catching and reproduction of patients symptoms.
- TFCC Press test – Detects TFCC tears. Patient sits on chair and grips side of chair then attempts to lift body weight off chair. Positive Sign- Reproducespatients symptoms normally ulnar sided wrist pain.
- Piano key test- Detects distal radioulnar joint instability. Clinician holds patients radius and ulnar and repeatedly moves bones in volar and dorsal directions throughout range of supination and pronation. Positive sign– distal radioulnar instability compared to the uninvolved side.
- Watson Scaphoid Test – Detects scapulolunate instability. Clinician places thumb on Lister’s tubercle and fingers of same hand on patients distal scaphoid tuberosity. Patients wrist is the ulnarly and radialy deviated both passively and actively. Positive sign – A click that reproduces patients symptoms in the dorsalradial wrist.
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