Wrist & Hand Evaluation

1. Wrist & Hand Evaluation Part Three

2. Special Tests • Compression test • Flick/tap test • Percussion test • Collateral stress (wrist) • Collateral stress (fingers) • Watson Clunk • Tinel’s sign • Digital Allen test • Phalen • Reverse Phalen • Murphy’s sign • DeQuervain’s/Finkelstein • Long Finger Flexion test • Paper/Froment sign • Bunnell-Littler test

3. Compression Test (fracture): • Examiner begins by grasping pt’s hand and compressing each digit along the long axis • Complete on all digits • Pain indicates a positive test for possible phalangeal fracture • Do not perform if an obvious deformity is present

4. Flick/Tap Test (fracture) • Stabilize pt’s finger with one hand and “flick” or tap the tip of pt’s finger with the index finger of the other hand • Repeat on all digits • Pain indicates a positive test for possible fracture

5. Percussion Test (fracture) • Stabilize pt’s hand with one hand and percuss pt’s fingers independently with the index finger of the other hand • Repeat on all digits • Pain indicates a positive test for possible fracture

6. Collateral Stress Test (wrist) (capsular laxity): • The examiner stabilizes the pt’s distal forearm with one hand while grasping the pt’s hand with the other • While holding the pt’s forearm in a neutral position, the examiner then applies valgus and varus forces to the pt’s wrist to test the integrity of the pt’s medial and collateral wrist ligaments, respectively

7. Collateral Stress Test (fingers) (laxity): • The examiner stabilizes the pt’s finger with the thumb and index finger of one hand and applies mild varus and valgus force to each of the interphalangeal joints with the thumb and index finger of the other hand, looking for laxity or abnormal joint opening that may be indicative of lateral and/or medial collateral ligament sprain • Repeat on all phalangeal articulations of all fingers

8. Watson Clunk Test (instability): • The examiner stabilizes pt’s distal radius and ulna with one hand and grasps the pt’s scaphoid bone with the thumb and index finger of the other • The examiner then attempts to translate the pt’s scaphoidanteriorly and posteriorly • Dislocation and/or subluxation indicates a positive test for scaphoid instability

9. Tinel’s Sign (at wrist) neuritis): • Examiner taps lightly over the pt’s transverse carpal ligament, looking for signs of paresthesia along the distal-most distribution of the median nerve • **Note: reflex hammer not required**

10. Digital Allen Test (arterial compromise): • The examiner instructs pt. to rapidly open and close the hand 15 times • As soon as the athlete finishes the final repetition, the examiner places his or her thumb over the pt’s radial artery and index finger over the pt’s ulnar artery • If pt’s hand remains cyanotic until after the examiner removes the pressure, then the test is positive for poor, impaired, and/or depressed perfusion (circulation) through the distal extremities

11. Phalen Test (CTS/neurologic impairment): • Position the patient with the dorsal aspect of both hands in full contact with both wrists maximally flexed • Instruct the patient to hold the position for 1 minute • Tingling or numbness radiating into the fingers (especially the palmar surface) indicates a positive test for median and/or radial nerve impairment

12. Reverse Phalen Test (carpal tunnel syndrome): • Instruct pt to perform a Phalen test with the wrists positioned in full extension and the palms in full contact • “Prayer hands” • Pt is instructed to hold the position for 1 minute while the examiner applies direct pressure over the athlete’s carpal tunnel • Tingling, numbness, and/or paresthesia indicates a positive test for carpal tunnel syndrome

13. Murphy’s Sign (lunate dislocation): • Examiner instructs pt to make a fist, then assesses contour of MCP joints • If third metacarpal is level with second and fourth metacarpals, lunate dislocation is suspected

14. DeQuervain’s (Finkelstein ) Test (DeQuervain’s disease): • Instruct pt to abduct the thumb so that it rests in the palm of the hand • Pt is then instructed to wrap the fingers over the thumb in order to make a fist • Examiner then stabilizes the wrist with one hand and applies a varus force to the wrist • Sharp pain on the lateral aspect of the wrist indicates a positive test for stenosingtenosynovitis to the abductor pollicuslongus and/or the extensor pollicusbrevis tendon sheath(s)

15. Long Finger Flexion Test (tendon rupture): • Independently isolate each of the pt’s interphalangeal joints, looking for obvious inability to flex which may be indicative of muscular lesion and/or avulsion • An inability to flex the DIP of any digit indicates a positive test for flexor digitorum profundus lesion • An inability to flex the PIP of any digit indicates a positive test for flexor digitorum superficialis lesion

16. Paper Test /Froment’s Sign (neurologic impairment): • Pt is instructed to hold a piece of paper between the 1st and 2nd digits by forcefully opposing those digits • The examiner then attempts to pull the paper out • An inability to hold the contraction and/or a weak contraction indicates a positive test for ulnar nerve impairment

17. Bunnel-Littler Test (hypomobility): • Examiner holds the pt’s MCP joint in slight extension while moving the PIP joint into flexion • If the PIP joint cannot be flexed, the test is positive for tight intrinsic muscles or contracture of the joint capsule • The examiner then slightly flexes pt’s MCP joint while moving the PIP into flexion again • If the PIP joint will flex, then the intrinsic muscles are tight • If the PIP joint will not fully flex, then the joint capsule is tight • Repeat on all digits