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Joe Godges DPT KP So Cal Ortho PT Residency
 
Red Flags for Potential Serious Conditions in Patients with Elbow, Wrist, or Hand Problems
References:1.
 
Harvey C. Compartment syndrome: when it is least expected.
Orthop Nurs
. 2001;20(3):15-23.2.
 
Jawed S, Jawad AS, Padhiar N, Perry JD
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Chronic exertional compartment syndrome of the forearms secondary to weighttraining.
 Rheumatology
2001;40:344-345.3.
 
Weinzweig N, Gonzalez M. Surgical infections of the hand and upper extremity: a county hospital experience.
 Ann Plast Surg.
2002 49;621-7.4.
 
Hunter JM, Mackin EJ, Callahan AD.
 Rehabilitation of the Hand and Upper Extremity
. 5th ed. Mosby,. 2002.5.
 
Phillips TG, Reibach AM, Slomiany WP, Diagnosis and management of scaphoid fractures
. Am Fam Physician.
 2004;70:879-884.6.
 
Bhowal B, Dias JJ, Wildin CJ. The incidence of simultaneous fractures of the scaphoid and radial head.
 J Hand Surg
.2001;26B:25-27.7.
 
Major N, Crawford S. Elbow effusion in trauma in adults and children: is there an occult fracture?
 Am J Radiology
.2002;178:413-418.8.
 
Bloack J, Sequeira W. Raynaud’s phenomenon.
 Lancet 
. 2001;357:9237.9.
 
Ciccone DS, Bandilla EB, WU. Psychological dysfunction in patients with RSD.
Pain
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Veldman HJM, Reynen HM, Arnitz IE, Goris RJA. Signs and symptoms of reflex sympathetic dystrophy: prospective studyof 829 patients.
 Lancet 
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American Cancer Society, What are the key statistics for melanoma? Revised 04-2004. http://www.cancer.org/docroot/CRI-2-4-1X
Red Flags for the Elbow, Wrist, and Hand RegionConditionRed FlagData obtained duringInterview/HistoryRed FlagData obtained duringPhysical Exam
CompartmentSyndrome
1,2
 History of trauma, surgery or extremeunaccustomed activityPersistent forearm pain and “tightness”Tingling, burning, or numbnessPalpable tenderness and tension of involved compartmentPain intensified with stretch to involved musclesParesthesia, paresis, and sensory deficitsDiminished pulse and prolonged capillary refillSpace Infection of theHand
3
 Recent cut, scrap, or puncture wound,such as a human or animal biteTypical symptoms of infection andinflammationKanavel cardinal signs: 1) flexed posture of the digit, 2)uniform swelling of the digit, 3) tenderness over thelength of the involved tendon sheath, and 4) severepain on attempted hyperextension of the digitLong Flexor TendonRupture
4
 Laceration in area of tendonForceful flexor contractionLoss of isolated DIP or PIP active flexionPossible palpable defect in involved muscleLunate Fracture orDislocation
4
 History or fall on hand or strainGeneralized wrist painPain at end ranges of wrist extensionDecreased grip strength/pain with grasping objectsScaphoid Fracture
5,6
History of fall on outstretched handPrevalent in males aged 15-30 andfemales with osteoporosis
 
Swelling, bruising around wristTenderness over anatomical snuff box/scaphoid tubercleIncreased pain with grippingDistal Radius (Colles’)FractureFall onto outstretched arm with forcefulwrist extensionYoung male or older femaleWrist swellingWrist held in neutral resting positionMovements into wrist extension are painfulRadial Head Fracture
7
History of fall on outstretched hand Elbow joint effusion - arm held in loose packed positionRestricted/painful supination & pronation AROMTenderness over radial head
Raynaud’sPhenomenon
8
 Positive family historyWomen on estrogen therapyCold exposure/frostbite injuryUnderlying collagen vascular disease
in pallor, cyanosis, and/or hyperemic erythema of the fingers
Taking medication promoting vasoconstriction such as B-blockers, amphetamines, decongestants, and caffeineComplex Regional PainSyndrome(Reflex SympatheticDystrophy)
9,10
 History of trauma or surgerySevere burning/boring/aching pain outof proportion to the inciting event
 
Pain not responsive to typical analgesicsSecondary hyperalgesia/hypersensitivityArea swollen (pitting edema), warm, and erythmatousTemperature difference between involved and uninvolvedextremity, hot or coldMelanoma
11
History of cancerFemale < 40 years of ageMale >40 years of ageFair skin, history of sunburns
A
symmetric or irregular shape lesion
B
orders are notched, scalloped or vaguely defined
C
olor uneven distributed or defined
D
iameter >6mm
 
 
Joe Godges DPT KP So Cal Ortho PT Residency
 
ELBOW, WRIST, HAND SCREENING QUESTIONNAIRE
NAME: ________________________________________ DATE: _____________Medical Record #: _________________________
Yes No1.
 
Have you recently had a trauma, such as a fall unto your hand?2.
 
Have you recently had a surgery for your neck, shoulder or arm?3.
 
Do you have numbness or tingling in your hands?4.
 
Has a doctor ever told you that you have osteoporosis (brittle bones)?5.
 
Have you recently had a sore, cut, scrape, or puncture wound, such asa human or animal bite?6.
 
Have you recently had an infection?7.
 
Have you recently or do you now have a fever?8.
 
Have you noticed an inability to move your wrist or elbow normally?9.
 
Do your easily hands or feet turn white or become painful when cold?10.
 
Have you noticed any newly formed or irregular moles on your body?11.
 
When you have pain, does it respond to pain medication?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cuong Pho DPT, Joe Godges DPT Loma Linda U DPT Program KPSoCal Ortho PT Residency1
Wrist Mobility Deficits
 ICD-9-CM codes
: 813.51 Colles’ fracture814.1 Fracture of scaphoid
 ICF codes
: Activities and Participation Domain codes:
d4301
Carrying in the hands;
d4401
 Grasping;
d4452
Reaching;
d4453
Turning or twisting the hands or armsBody Structure code:
s73011
Wrist jointBody Functions code:
b7202
Mobility of carpal bones
Common Historical Findings
:Trauma (e.g., fall unto outstretched hand with wrist extended)ROM limitation due to effusion or pain if acuteStiffness following immobilization and healingWrist pain - worse at endrange of one motion more than others
Common Impairment Findings
 
- Related to the Reported Activity Limitation or Participation Restriction:
 ROM deficits (ext/flex/sup/pron)Pain at end of range of limited ROMHypomobile radiocarpal, ulnomensicotriquetral, distal radioulnar, and/or intercarpalaccessory movement tests
Physical Examination Procedures
:Pain at end range of certain motionsIf pain and motion abnormality is with pronation - primarily assess distalradioulnar jointIf pain and motion abnormality is with supination - primarily assessulnomeniscotriquetral jointsIf pain and motion abnormality is with extension - primarily assessradiocarpal jointsIf pain and motion abnormality is with flexion - primarily assessintercarpal jointsWrist Accessory Movement TestDistal Radioulnar JointWrist Accessory Movement TestUlnomeniscotriquetral Joints
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