By

Mohammad Amjad Khan

M.P.T (Neurological and Psychosomatic Disorders)
Doctor of Physical Therapy
MIAP,MMPA,MRCSK,MNASAM,MMFTI,CYT
Lecturer,IIUM,Malaysia
Department Of Physical Rehabilitation Sciences.
 Thehand and wrist are the most active
and intricate parts of the upper extremity.

 Because of this, they are vulnerable to

injury, which can lead to large functional
difficulties.
 Their
mobility is enhanced by a wide
range of movement at the shoulder an
complementary movement at the elbow.

 The 28 bones, numerous articulations,

and 19 intrinsic and 20 extrinsic muscles
of the wrist and hand provide a
tremendous variability of movement.
 In addition to being an expressive organ
of communication, the hand has a
protective role and acts as both a motor
and a sensory organ, providing
information such as temperature,
thickness, texture, depth, and shape as
well as the motion of an object.
 It is this sensual acuity that enables the
examiner to accurately examine and
palpate during an assessment.
 The distal radioulnar
joint is a uniaxial
pivot joint that has
one degree of
freedom
The radiocarpal (wrist)
joint is a biaxial
ellipsoid joint,The
radius articulates
with the scaphoid
and lunate.
 The assessment of the forearm, wrist, and
hand often takes longer than that of other
joints of the body because of the
importance of the hand to everyday
function and because of the many
structures and joints involved .
1) What is the patient"s age?
 Certain conditions are more likely to
occur" at different ages.
 For example, arthritic changes are most
commonly seen in patients who are older
than 40 years of age
2) What is the patients occupation?

 Certain occupations are more likely to

affect the wrist and hand.
 For example, typists are more likely to
suffer repetitive strain injuries, and
automobile mechanics are more likely to
suffer traumatic injuries.
3) What was the mechanism of injury?
 For example, a fall on the outstretched hand
(FOOSH) injury may lead to a lunate
dislocation , Colles fracture, or scaphoid
fracture,
 or extension of the fingers may cause
dislocation of the fingers.
 A rotational force applied to the wrist or
near it may lead to a Galeazzi fracture,
which is a fracture of the radius and
dislocation of the distal end of the ulna.
 4) what tasks is the patient able or unable
to perform?
 For example is there any problem with
buttoning, dressing, tying shoelaces or
any other everyday activity?
 This type of question gives an indication
of the
patient's functional limitations.
 5)When did the injury! or onset occur, and
how long has the patient been
incapacitated?

 6) Which hand is the patient's dominant

hand?
 The dominant hand is more likely to be
injured, and the functional loss, at least
initially, is greater
 7)Has the patient injured the forearm,
wrist, or hand previously?

 Was it the same type of injury?

 Was the mechanism of injury the same?

 If so, how was it treated?

 8)Which part of the forearm, wrist, or
hand is injured?

 Ifthe flexor tendons are injured, they

respond much more slowly to treatment
than do extensor tendons.
 While observing the patient and viewing
the forearms, wrists, and hands from both
the anterior and posterior aspects, the
examiner should note the patient‘s ability
to use the hand.
 Are the normal skin creases present?
 Skin creases occur because of movement
at the various joints.
 The examiner should note any muscle
wasting on the thenar eminence (median
nerve )
 or hypothenar eminence (ulnar nerve)
that may be indicative of peripheral
nerve or nerve root injury.
 Thepresence of any wounds or scars
should be noted because they may
indicate recent surgery or past trauma.

 Anyulcerations may indicate

neurological or circulatory problems.
 Swan-Neck Deformity
 There is flexion of the
metacarpo phalangeal
and distal
interphalangeal joints,
but the real deformity is
extension of the proximal
interphalangeal joint.
 The condition is a result
of contracture of the
intrinsic muscles and is
often seen in patients
with rheumatoid arthritis
or following trauma
 Extension of the
metacarpophalangeal
and distal
interphalangeal joints
and flexion of the
proximal interphalangeal
joint
 The deformity is the
result of a rupture of the
central tendinous slip of
the extensor hood and is
most common after
trauma or in rheumatoid
arthritis
 This deformity, which is
commonly seen in
patients with rheumatoid
arthritis but can occur
with other conditions,
results in ulnar deviation
of the digits because of
weakening of the
capsuloligamentous
structures of the
metacarpophalangeal
joints
 This deformity results from the
loss of intrinsic muscle action
The metacarpophalangeal
joints are hyperextended, and
the proximal and distal
interphalangeal joints are
flexed .
 If intrinsic function is lost, the
hand is called an intrinsic
minus hand and there is
intrinsic muscle wasting.
 The deformity is most often
caused by a combined
median and ulnar nerve palsy.
 This deformity is the result of a thickening of the flexor
tendon sheath, which causes sticking of the tendon when the
patient attempts to flex the finger.
 When the patient attempts to flex the finger, the tendon
sticks, and the finger " lets go," often with a snap. As the
condition worsens, eventually the finger will flex but not let
go, and it will have to be passively extended. The condition
is more likely to occur in middle-aged women,
 whereas "trigger thumb“ is more common in young children.
 The condition usually occurs in the third or fourth finger.
 It is most often associated with rheumatoid arthritis and
tends to worse in the morning.
 Wasting of the thenar
eminence of the hand
occurs as a result of a
median nerve palsy,
and the thumb falls
back in line with the
fingers as a result of
the pull of the extensor
muscles.
 The patient is also
unable to oppose or
flex the thumb.
 The thumb is flexed
at the
carpometacarpal
joint and hyper
extended at the
metacarpophalangea
l joint .
 The deformity is
associated with
rheumatoid arthritis
 This condition is the result of
contracture of the palmar fascia.
 There is a fixed flexion deformity
of the metacarpophalangeal and
proximal interphalangeal joints .
 Dupuytren's contracture is usually
seen in the ring or little finger,
and the skin is often adherent to
the fascia.
 It affects men more often than
women and is usually seen in the
50- to 70-year-old age group.
A mallet finger
deformity is the
result of a rupture or
avulsion of the
extensor tendon
where it inserts into
the distal phalanx of
the finger.
 The distal phalanx
rests in a flexed
position.
 Wasting of the
hypothenar muscles
of the hand, the
interossei muscles
occurs because of
ulnar nerve palsy
Flexion of the fourth
and fifth fingers is the
most obvious
resulting change.
 The extensor muscles
of the wrist are
paralyzed as a result
of a radial nerve
palsy and the wrist
and fingers can not
be actively extended
by the patient.
 Chronic respiratory disorders produce
clubbing of the nails
 Congenital heart disease may produce
cyanosis and nail clubbing
 Parkinson's disease produces a typical
hand tremor known as "pin rolling hand“
 "Opera glove" anesthesia is seen in
leprosy,and diabetes. It is a condition in
which there is numbness from the elbow
to the fingers
 In some cases, the examiner may want to
test the Iength of the long extensor and
flexor muscles of the wrist.
 If the length of the muscles is normal, the
passive range on testing will be full and the
end feel will be the normal joint tissue
stretch end feel.
 If the muscles are tight, the end feel will be
muscle stretch, which is not as "stretchy" as
tissue or capsular stretch, and the ROM will
be restricted.