2019-10-31

Purpose

•  Establish baseline status

Hand Evalua*on •  Validate progress
•  Professional communica=on
•  Research

History General Informa=on

•  Demographic data •  Medical history
•  Diagnosis, Date of onset •  Social history
•  Mechanism of injury •  Occupa=on
•  Past medical history •  Hobbies & interests
•  Main complaints
•  Pa=ent’s goals & expecta=ons

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Subjec=ve Complaints Observa=on

•  ANtude towards injury
•  Complaints of pain
•  Appearance
•  Sensa=on •  Colour/Circula=on
•  How func=on is impaired •  Sudomotor func=on
•  Atrophy
•  Posture of digits

Observa=on Palpa=on

•  Edema
•  Areas of tenderness
•  Fascial cords/
nodules/callous

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Equipment for Examina=on Assessment of Edema

•  Goniometer
•  Two-point caliper
•  Semmes-Weinstein monofilaments
•  Dynamometer
•  Pinch gauge
•  Tape measure, volumeter
l Circumferen=al

l Volumetric

Assessment of ROM Recording ROM Measurements

•  Use standardized
goniometric
measurements •  AROM PIP Ext/Flex
30/75 30-75
•  0 degree neutral
star=ng posi=on •  PROM PIP Ext/Flex
•  Documenta=on – 10/85 10-85
frequent
•  Factors affec=ng ROM

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Tendon Status EIP & EDM Test

•  EDC test

EPL Test Flexor Tendons

FDS Test FDP Test

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Tendon Func=on
To Assess Extrinsic Muscle-Tendon Unit
Tightness, the Wrist Posi=on is the Key

Tendon Excursion

Extrinsic Flexor Tightness

To Assess Extrinsic Muscle-Tendon Unit
Tightness, the Wrist Posi=on is the Key
•  With wrist
•  Occurs from origin extended, finger
to inser=on extension is limited
•  Most prominent
•  With wrist flexed,
joint crossed by the
muscle-tendon unit Finger extension
is the key to assess improves
=ghtness

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Extrinsic Flexor Tightness Extrinsic Extensor Tightness

•  With wrist flexed,

finger flexion is
limited
•  With wrist
extended, finger
flexion improves

Evalua=on of Ar=cular/Periar=cular
Extensor Tightness
Tightness

•  Goniometric
measurements remain
unchanged
irrespec=ve of the
wrist posi=on

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Ar=cular/Periar=cular Tightness Intrinsic Tightness

•  The MCP posi=on is

the key to assess the
intrinsic =ghtness

Intrinsic Tightness Oblique Re=nacular Ligament

Tightness

•  The PIP joint posi=on

is the key to assess
the oblique
re=nacular =ghtness

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Web Space Contracture Neuro-Muscular Func=on

•  Radial Nerve Func=on

–  Posterior Interosseous Nerve
•  Median Nerve Func=on
–  Anterior Interosseous Nerve
•  Ulnar Nerve Func=on

Radial Nerve Lesion Radial Nerve

•  Closed injuries – differen=al diagnosis
•  Open Injuries – essen=al to assess proximal vs distal trauma
assessment simpler
•  Saturday Night Palsy
•  Findings obvious
•  Loss of wrist & digital •  Mid shae humeral fractures
extension
•  Loss of BR, Supinator,
Ticeps func=on

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Posterior Interosseous Nerve Posterior Interosseous Nerve

•  Fibrilla=on of Supinator – proximal trauma
•  Entrapment at •  Classic radial devia=on in extension with loss
proximal & distal
of digital extension
edges of supinator -
Arcade of Froshe •  Par=al paralysis – Loss of 4th & 5th MCP
extension, at =mes loss of 3rd & 4th MCP
•  Involvement of EDC,
extension
EDM,ECU, EPL & B,
and EIP
R
F OSHE

RADIAL NERVE

Median Nerve Lesion Comparison of Findings

•  Entrapment at superficialis arch

distally, ligament of Struthers,
lacertus fibrosus and deep head
of pronator teres
•  Carpal tunnel syndrome
•  Anterior interosseous syndrome
•  Differen=al diagnosis – for
proximal vs distal lesions

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Classic Tests – Median Nerve

Anterior Interosseous Syndrome
Lesions
•  Acute demyelina=on
•  Denerva=on of FPL, FDP – D2 & D3, and
•  Phalen’s test pronator quadratus
•  Reverse Phalen’s •  Benedic=on Sign – Posi=ve
•  Tinel’s •  Anastomo=c varia=on – Mar=n Gruber
Anastomosis

Ulnar Nerve Lesions Nerve Lesion - Elbow

•  Lesions - Cubital Tunnel, •  Denerva=on of FCU,

Arcade of Struthers, profundii – D4 & D5,
tendinous origin of FCU, and muscles supplied by
fracture disloca=ons, ulnar nerve distally
Guyon’s canal •  No or minimal clawing
•  Lesions proximal to elbow •  Wartenburg’s sign -
– Cervical foramina, and posi=ve
Thoracic Outlet
UTHERS
STR
ULNAR NERVE

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Nerve Lesion – Distal to Elbow Classic Tests – Ulnar Nerve Lesions

Egawa Froment’s
•  Denerva=on of
Palmar & Dorsal
Interooseii, intrinsic
muscles of the small
finger, adductor
Cross Finger
pollicis, and deep
fibers of FPB
•  Clawing profound

Provoca=ve Tests Strength

•  Ar=cular Status – OA •  Measurement of grip & pinch strength
•  Posi=onal Tests – Nerve & Tendon Status important once adequate mobility is restored
•  Resisted Mo=on Tests – Nerve & Tendon •  Strength measurements offer a gross
Status assessment of pa=ent’s power & precision
•  Resisted/Loading Tendon Tests – handling
Inflammatory process tendons •  Many factors can influence measurements

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Grip Strength Pinch Strength

Func=onal/ADL Assessment Sensibility

•  Minnesota rate of •  Normal sensibility is a

manipula=on test prerequisite to normal
hand func=on
•  Jebson-Taylor hand
•  Hypersensi=vity vs
func=on test desensi=zed
•  Purdue pegboard •  Important to ini=ate
test appropriate
•  Other therapeu=c
techniques

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Sensibility Tes=ng Conclusion

•  Protec=ve sensa=on
•  Vibra=on – 30 cps, 256, cps In-depth understanding of anatomy and
•  Moving touch assessment is pre-requisite to the
•  2 Point discrimina=on management of all common hand
•  Semmes-Weinstein Monofilament disorders
•  Localiza=on
•  Func=onal-Moberg Pickup Test

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