History of Present Illness
Age, sex, occupation, hand dominance, problem. Ask about pain, numbness, tingling, weakness, discoloration, coldness, clumsiness, clicking/snapping. Identify location, intensity, duration, frequency, radiation, assoc sx. Treatments to date. Aggravating/alleviating factors. For injuries note mechanism, time, place, position hand was in at time of injury, previous injury. Last meal and tetanus immunization.
Past Medical History
Diabetes, gout, RA, CAD, pulmonary, renal disease, bleeding problems.
Medications
Especially anticoagulants, rheumatoid agents
Allergies
Social History
Tobacco and EtOH use. Substance abuse, hobbies, work
Family History
ROS
Physical Exam
Inspect hand for discoloration, deformity, atrophy, trophic change (sweat pattern, hair growth), swelling, wounds/scars.
Palpate for masses, temp abnormalities, tenderness, crepitans, clicking/snapping, joint effusion.
ROM; passive yields info about joint stiffness, active gives info regarding tendon continuity, nerve f’n, muscle strength. Nml finger ext 0 degrees, nml flexion: MCP 85, PIP 110, DIP 65.
Assess stability of joints (MCP joints tighter if lexion).
Muscle tendon assessment (grading strength 1-5): FPL (flex IP thumb), FDP (flex DIP only in finger), FDS (flex PIP while other fingers blocked in extension), FCU/FCR (volar flex wrist). Dorsal compartments: 1) APL & EPB (bring thumb out to the side), 2) ECRL & ECRB (make a fist and bring wrist back strongly), 3) EPL (place hand flat on table and lift thumb off), 4) EDC & EIP (straighten fingers at MCP joint), 5) EDM (straighten 5th finger), 6) ECU (pull hand up and to the side. Test extensor tightess vs PIP contracture by passive flexion of PIP with MCP both flexed and extended. Evaluate thenar muscles (APB, OP, & FPB) by asking pt to touch thumb & small fingertips together so nails are parallel (median n). AdP (ulnar n) by asking pt to hold piece of paper btwn thumb & radial side of index (when thumb IP flexes called Froment’s sign). Interosseous (ulnar n) ask pt to spread fingers apart. Hypothenar muscles (ADM, FDM, ODM) evaluated by asking pt to bring small finger away from others.
Nerves assessment: radial n (ext thumb IP) recurrent motor median (palmar abduction of thumb), AIN (OK sign [flexion of thumb and index IP]), ulnar n (cross fingers). Sensory f’n: radial (dorsal 1-2 web space), median (palmar index), ulnar (palmar little finger). Individual digital nerve f/n assessed radial and ulnar. Test light touch, two-point discrimination, temp, Semmes-Weinstein monofilament.
Vascular Assessment: arterial disruption (white or grey), venous blockage (purple-blue). Coolness, abnormal turgor, subungual splinter hemorrhage (caused by arterial lesion or embolism). Cap refill (nml < 2s), Allen’s test.
Special Tests:
-Grind test: stabilize both sides of CMC & apply axial load while rotating (pain indicates CMC arthritis/abnormality).
-Finkelstein’s test: pt makes a fist with thumb under and ulnar deviation at wrist (pain in 1st dorsal compartment indicates inflammation of EPL, EPB, APL, called DeQuervain’s tendinitis)
-FDP: flex DIP with MCP and PIP in extension.
-FDS: flex finger with other fingers held in extension (profundus share a common origin).
-Bunnel’s test: MCP held in extension and passively flex PIP, then flex MCP and passively flex PIP (if PIP can be flexed when MCP extended but not flexed, then indicates intrinsic tightness)
-Extrinsic tightness test: PIP joint can be passively flexed with MCP joint extended, not flexed.
-Scaphoid stability: palpate scaphoid distal pole volarly, in ulnar deviation scaphoid extended, flexes in radial deviation of wrist. If radial & ulnar deviation do not change distal pole position then incompetence of scapho-lunate ligament.
-Triquetrolunate Ballotment Test (LT Shear): lunate stabilized by examiners thumb & index finger with wrist in neutral, examiner pushes on triquetrum in a dorsal direction (pain or instability indicates instability of triquetrolunate ligament)
-Ulnar Carpal Abutment Test: stabilize wrist & move wrist into maximum ulnar deviation (reproduction of pain or a click/pop indicates TFCC tear).
-Gamekeeper’s test: stabilize pts thumb mc and prox phalynx, with MCP fully extended apply gentle radial deviation, then with joint in 30 degrees of flexion, if laxity is present determine whether there is an endpoint (stresses ulnar collateral ligament).
-Prune test: finger held in cup of water for 5-10 min, with normal sensory innervation will wrikle up. If not, indicates sensory interruption.
-Tinel’s test: examiner percusses over the distal palmar crease in the midline (positive for CTS if pt reports paresthesias in median n distribution)
-Phalen’s test: pts wrist held in maximum flexion for 2 min (paresthesias in median n distribution indicates CTS).
-Froment’s sign: pt hold paper btwn thumb & index fingers while examiner tries to pull it away (if there is weakness of thumb adductor [ulnar n], pt will flex thumb IP joint.
-Jeanne’s sign: loss of lateral or key pinch of thumb (weakness of adductor pollicis, ulnar n).
-Wartenberg’s sign: pt asked to hold all fingers extended and fully adducted, and the small finger will remain abducted (indicates ulnar n motor weakness because 3rd palmar interosseous is weak and edm is unopposed).
-Semmes-Weinstein monofilament and two point discrimination (nml 6 mm) tests for earlier detection of sensory dysfunction.
-Allen’s test: can be done at wrist or fingers. Wrist: pt makes tight fist, examiner occludes radial & ulnar a, pt opens hand which is now white. Examiner releases radial a & notes time until fingers turn pink (< 6s nml). Then repeat with releasing ulnar a instead (occlusion of artery demonstrated by prolonged refill times).
-Grip strength assessed by dynamometer
-Pinch strength can be assessed by pinch dynamometer (key pinch is thumb tip to radial aspect of middle phalanx of index). Record 3 and calculate avg. (tip pinch value or reverse key pinch is index tip to ulnar tip of thumb)
CTS: thenar atrophy, decreased sweat production radially, thenar wasting, decr palmar abduction thumb, tinel’s, phalen’s
Trigger finger: motion elicits catching, locking
Dupytren’s: contracture, nodule
DeQuervain’s: Finklestein test
TFCC tears: pain on ulnar side of wrist, clicking with wrist deviation & forearm rotation, TTP just distal to ulna, ulnar carpal abutment test
Radiographic Exam
Assessment
Plan