MusculoSkeletal Exam
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Chapter 10 The Wrist and Hand
Figure 10.34 Passive movement testing of flexion of the metacarpophalangeal joint.
Figure 10.35 Passive movement testing of extension of the metacarpophalangeal joint.
(Kaltenborn, 1999; Magee, 1997). The collateral ligaments of the metacarpophalangeal joints are taut in flexion and relaxed in extension. You will note that the presence of abduction or adduction of the metacarpophalangeal joint in a flexed position is due to collateral ligament discontinuity or rupture. Normal range of motion is 0–20 degrees (Hoppenfeld, 1976) (Figure 10.36).
Proximal and Distal Interphalangeal Joint Flexion
The forearm should be positioned midway between pronation and supination with the wrist in the neutral position. The metacarpophalangeal joint should be
at 0 degrees of flexion–extension and abduction– adduction. Place your thumb and index fingers on the proximal phalanx of the finger being examined to stabilize it. Use your other index finger and thumb to hold the middle phalanx and move the proximal interphalangeal joint into flexion. To assess the distal interphalangeal joint, with the hand in the same position, stabilize the middle phalanx and move the distal phalanx into flexion. The motion of the proximal interphalangeal joint can be restricted by contact between the middle and proximal phalanges, producing a hard end feel. A soft end feel is possible secondary to compression of soft tissue on the volar aspect. The
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Figure 10.36 Passive movement testing of abduction and adduction of the metacarpophalangeal joint.
motion of the distal interphalangeal joint can be restricted by tension in the dorsal aspect of the capsule or the collateral ligaments, producing an abrupt and firm (ligamentous) end feel (Kaltenborn, 1999; Magee, 1997). Normal range of motion is 0–110 degrees for the proximal interphalangeal joint and 0–65 degrees for the distal interphalangeal joint (American Society for Surgery of the Hand, 1983) (Figure 10.37).
Proximal and Distal Interphalangeal Joint Extension
The position and stabilization used for proximal and distal interphalangeal joint extension are the same as those listed for flexion. Grasp the middle phalanx (proximal interphalangeal joint) or the distal phalanx (distal interphalangeal joint) and return the joint to extension. The motion of the proximal and distal interphalangeal joints can be restricted by tension in the volar aspect of the capsule, producing an abrupt and firm (ligamentous) end feel (Kaltenborn, 1999;
Magee, 1997). Normal range of motion is 0 degrees for the proximal interphalangeal joint and 0–20 degrees for the distal interphalangeal joint (Hoppenfeld, 1976) (Figure 10.38).
First Carpometacarpal Abduction and Adduction
The forearm should be positioned midway between pronation and supination with the wrist in the neutral position. The metacarpophalangeal joint should be at 0 degrees of flexion–extension and abduction– adduction. The carpometacarpal, metacarpophalangeal, and interphalangeal joints of the thumb should all be at 0 degrees. Place your hand around the carpal bones and the second metacarpal to stabilize the hand. Using your other thumb and index finger, grasp the first metacarpal and move the thumb and metacarpal away from the palm, creating abduction. Check adduction by returning the thumb to the palm. Carpometacarpal abduction is restricted by fascial tension in the web
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Proximal interphalangeal joint
Figure 10.37 Passive movement testing of flexion of the proximal and distal interphalangeal joints.
PIP joint
Figure 10.38 Passive movement testing of extension of the proximal and distal interphalangeal joints.
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space and tension in the intrinsic muscles, producing an abrupt and firm (ligamentous) end feel (Kaltenborn, 1999; Magee, 1997). Normal range of motion is 0–70 degrees for abduction and 0 degrees for adduction (American Academy of Orthopedic Surgeons, 1965) (Figure 10.39).
Opposition
The forearm should be positioned in supination with the wrist at 0 degrees of flexion–extension and abduc- tion–adduction. The interphalangeal joints of the thumb and fifth finger should be at 0 degrees. Using your thumb and index and middle fingers, grasp the fifth metacarpal. Use the same grasp with your other hand on the first metacarpal. Approximate the first and fifth metacarpals (Figure 10.40). Soft-tissue contact of the thenar and hypothenar eminences can produce a soft end feel. Tension in the posterior aspect of the joint capsules or in the extensor muscles can produce an abrupt and firm (ligamentous) end feel (Kaltenborn, 1999; Magee, 1997). Loss of range of motion is determined by measuring the distance between the finger pads of the first and fifth fingers.
Thumb Metacarpophalangeal Flexion
The positions of the patient and examiner for testing thumb metacarpophalangeal flexion are the same as those described in the section on metacarpophalangeal flexion of fingers two through five. Use your thumb
1st CMC joint
Figure 10.39 Passive movement testing of abduction and adduction of the first carpometacarpal (CMC) joint.
and index finger to grasp the first metacarpal and carpometacarpal joint to stabilize them. The movement is accomplished by grasping the proximal phalanx of the thumb and moving it across the palm toward the hypothenar eminence. The motion can be restricted by
Figure 10.40 Passive movement testing of opposition.
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Thumb MCP joint
Figure 10.41 Passive movement testing of flexion of the thumb |
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metacarpophalangeal (MCP) joint. |
Figure 10.42 Passive movement testing of extension of the |
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thumb metacarpophalangeal joint. |
tension in the collateral ligaments, the dorsal aspect of the capsule, or the extensor pollicis brevis tendon producing an abrupt and firm (ligamentous) end feel. A hard end feel is possible if contact occurs between the proximal phalanx and the first metacarpal (Kaltenborn, 1999; Magee, 1997). Normal range of motion is 0–50 degrees (American Academy of Orthopedic Surgeons, 1965) (Figure 10.41).
Thumb Metacarpophalangeal Extension
The positions of the patient and the examiner for thumb metacarpophalangeal extension are the same as those described in the section on metacarpophalangeal extension of fingers two through five. Use your thumb and index finger to grasp the first metacarpal and carpometacarpal joint to stabilize them. The movement is accomplished by the examiner grasping the proximal phalanx of the thumb and moving it laterally away from the palm and opening the web space. The motion can be restricted by tension in the volar aspect of the capsule or the flexor pollicis brevis tendon, producing an abrupt and firm (ligamentous) end feel (Kaltenborn, 1999; Magee, 1997). Normal range of motion is 0 degrees (American Academy of Orthopedic Surgeons, 1965) (Figure 10.42).
Thumb Interphalangeal Joint Flexion and Extension
The positions of the patient and the examiner and stabilization for thumb interphalangeal flexion and extension are the same as those described in the section
Figure 10.43 Passive movement testing of flexion and extension of the thumb interphalangeal joint.
on interphalangeal flexion and extension of fingers two through five. The end feels and limiting factors are also the same. The normal range of motion for interphalangeal flexion is 0–80 degrees and for interphalangeal extension it is 0–20 degrees (American Academy of Orthopedic Surgeons, 1965) (Figure 10.43).
Mobility Testing of Accessory
Movements
Mobility testing of accessory movements will give you information regarding the degree of laxity present in the joint. The patient must be totally relaxed and
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comfortable to allow you to move the joint and obtain the most accurate information. The joint should be placed in the maximal loose packed (resting) position to allow for the greatest degree of joint movement. The resting position of the wrist is as follows: The longitudinal axes of the radius and the third metacarpal form a straight line with slight ulnar deviation (midposition between ulnar and radial deviation). The resting position of the first carpometacarpal joint is with the metacarpal midway between abduction– adduction and flexion–extension. The resting position of the fingers is slight flexion of all joints (plus slight ulnar deviation of the second through fifth metacarpophalangeal joints) (Kaltenborn, 1999).
Ventral and Dorsal Glide of the Radius and
Radial Head
Refer to Chapter 9 (p. 215) for a full description of these mobility tests.
Traction of the Radiocarpal Joint
Place the patient in the sitting position, with the arm pronated and supported on the treatment table. The wrist should be in the neutral position. Stand so that you are facing the ulnar aspect of the wrist. Stabilize by grasping the dorsal distal aspect of the forearm with your hand. Wrap your other hand around the proximal row of carpals, just distal to the radiocarpal joint. Pull the carpals in a longitudinal direction until you have taken up the slack, producing traction in the radiocarpal joint (Figure 10.44).
Traction of the Midcarpal Joint
Place the patient in the sitting position, with the arm pronated and supported on the treatment table. The wrist should be in the neutral position. Stand so that you are facing the ulnar aspect of the wrist. Stabilize by grasping the dorsal aspect of the proximal carpal row with your hand. Wrap your other hand around the distal row of carpals. Pull the distal row of carpals in a longitudinal direction until you have taken up the slack, producing traction in the midcarpal joint (Figure 10.45).
Individual Carpal Joints
Each of the individual carpal bones can be moved on each other at their specific articulations. Description of these techniques is beyond the scope of this book.
Figure 10.44 Mobility testing of traction of the radiocarpal joint.
Figure 10.45 Mobility testing of traction of the midcarpal joint.
The reader should consult a text on mobilization for further details.
Palmar and Dorsal Glide of the Metacarpals
Place the patient in the sitting position, with the forearm pronated and supported on the treatment table. The wrist should be in the neutral position. Stand so that you are facing the dorsal aspect of the hand. Grasp the third metacarpal with your thumb and then
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Stabilizing |
MCP joint |
hand |
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Figure 10.47 Mobility testing of traction of the metacarpophalangeal (MCP) and proximal and distal interphalangeal joints.
Figure 10.46 Mobility testing of palmar and dorsal glide of the metacarpals.
wrap your fingers around the palmar surface. Using the same hold with your other hand, move the second metacarpal first in a dorsal and then a volar direction until all the slack is taken up in each direction. This can be repeated for the fourth and fifth metacarpals (Figure 10.46).
Traction of the Metacarpophalangeal and Proximal
and Distal Interphalangeal Joints
Place the patient in a sitting position, with the forearm pronated. Sit facing the patient so that you can hold the ulnar aspect of the patient’s hand against your body. Grasp the metacarpal just proximal to the metacarpophalangeal joint to stabilize it. Using your thumb and index finger, grasp the proximal phalanx. Pull in a longitudinal direction until you have taken up the slack, producing traction in the metacarpophalangeal joint. To produce traction in the proximal interphalangeal joint, the stabilization is moved to the proximal phalanx and the middle phalanx is mobilized. To produce traction in the distal interphalangeal joint, the stabilization is moved to the middle phalanx and the distal phalanx is moved (Figure 10.47).
Traction of the First Carpometacarpal Joint
Place the patient in a sitting position, with the forearm midway between supination and pronation. Stand so that you are facing the dorsal aspect of the hand. Using your thumb and index finger, grasp the trapezeii for stabilization. Using the thumb and index finger of your other hand, grasp the proximal aspect of the first metacarpal, just distal to the carpometacarpal joint. Pull in a longitudinal direction until you have taken up all the slack, producing traction in the first carpometacarpal joint (Figure 10.48).
Ulnar Glide of the First Metacarpophalangeal Joint
Place the patient in a sitting position, with the forearm midway between supination and pronation. Stand so that you are facing the dorsal aspect of the hand. Using your thumb and index finger, grasp the first metacarpal for stabilization. Using the thumb and index finger of your other hand, grasp the proximal aspect of the proximal phalanx and glide it in an ulnar direction until all of the slack is taken up (Figure 10.49). Rupture of the ulnar collateral ligament of the first metacarpophalangeal joint is known as gamekeeper’s or skier’s thumb (Figure 10.50).
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Ulnar collateral ligament being stretched
Figure 10.49 Mobility testing of ulnar glide of the first metacarpophalangeal joint.
Figure 10.48 Mobility testing of traction of the first carpometacarpal joint.
Resistive Testing
The Wrist
The primary movements of the wrist are flexion and extension. The wrist is also able to deviate in the radial and ulnar directions because of the attachments of the flexor and extensor muscles of the wrist on the radial and ulnar borders of the hand.
Flexion
The flexors of the wrist are the flexor carpi radialis (Figure 10.51) and flexor carpi ulnaris (Figure 10.52). They are assisted by the flexor digitorum superficialis and profundus.
Ruptured ulnar collateral ligament
Figure 10.50 Gamekeeper’s (skier’s) thumb.
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Palmaris longus
Flexor carpi radialis
Figure 10.51 The flexor carpi radialis muscle.
Flexor carpi ulnaris
Figure 10.52 The flexor carpi ulnaris muscle.
•Position of patient: Sitting or supine. The forearm is supinated.
•Resisted test: Support the patient’s forearm with one hand and ask the patient to flex the wrist so that the hand moves directly upward, perpendicular to the forearm. If you ask the patient to flex the wrist radially and apply resistance proximal to the thumb, you will isolate the flexor carpi radialis (Figure 10.53). Likewise, if you ask the patient to flex the wrist in an ulnar direction and you apply resistance to the hypothenar eminence, you will isolate the flexor carpi ulnaris muscle (Figure 10.54).
Testing wrist flexion with gravity eliminated is performed by asking the patient to place the hand and forearm on a table with the forearm midway between pronation and supination, and to flex the wrist with the table supporting the weight of the hand and forearm.
Weakness of wrist flexion results in difficulty with feeding oneself and performing personal hygiene.
Extension
The extensors of the wrist on the radial side are the extensor carpi radialis longus and brevis (Figure 10.55). The extensor of the wrist on the ulnar side is the extensor
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Flexor carpi radialis
Figure 10.53 Testing wrist flexion, isolating the flexor carpi radialis.
Flexor carpi ulnaris
Figure 10.54 Testing wrist flexion while isolating the flexor carpi ulnaris.
carpi ulnaris (Figure 10.56). These muscles are assisted by the extensor digitorum, extensor indicis, and extensor digiti minimi.
•Position of patient: Sitting with the elbow slightly flexed.
•Resisted test: Support the patient’s pronated forearm on the treatment table and ask the
patient to extend the wrist in the line of the forearm while you apply resistance to the dorsum of the hand (Figure 10.57). You can isolate the extensor carpi radialis longus and brevis by applying resistance along the second and third metacarpals. The patient should try to extend the wrist in a radial direction. You can isolate the
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