TESTS
POSITION OF THE HAND & WRIST
STRUCTURES INVOLVED
DESCRIPTION OF TEST BEING PERFORMED
MOUSE OVER PICTURE TO VIEW MOVIE
Murphy's Sign
Ask the patient to make a fist.
Tests for dislocation of the lunate.
As the examiner, visually inspect the dorsal aspect of the hand. Normally the knuckle formed by the head of the third metacarpal is more prominent and protrudes further distally as compared to the knuckles of the second and fourth metacarpal heads. If the knuckle of the third metacarpal head is level with the knuckles of the second and fourth metacarpal heads, the sign is positive and indicative of a lunate dislocation.
Anatomical Snuffbox Compression Test
The patient should rest the involved forearm on the table. Then, ask the patient to extend the thumb so that these tendons become prominent.
Pain in the anatomical snuff-box is an indication of a scaphoid fracture.
The anatomical snuff box is formed by space between the abductor pollicis longus and extensor pollicis brevis tendons on the radial border and the extensor pollicis longus tendon on the ulna side. As the examiner, you should then press in the anatomical snuffbox, applying compression to the scaphoid navicular bone. Pain with palpation of the snuffbox is indicative of a scaphoid fracture, particularly if the patient also has pain in the same area with passive wrist hyperextension.
The patient sits with the forearm supported on the table in a neutral position. The hand should be free to hang over the table edge. Instruct the patient to make a fist with the thumb inside the fingers, deviating the wrist to the ulnar side.
Determines presence of tenosynovitis (De Quervain's disease or Hoffman's disease) in the abductor pollicis longus and the extensor pollicis brevis tendons of the thumb.
You may accentuate the test by using one hand to stabilize the distal forearm while placing your other hand over the fist's radial side to push the wrist into further ulnar deviation. This maneuver will cause a stretching in these tendons which is painful if tenosynovitis is present. Additional positive findings may be accomplished by asking the patient to begin with the wrist in full ulnar deviation and then to actively abduct or radially flex the wrist against your manual resistance.
Boutonniere Deformity Test
Position the patient with the forearm in pronation and the hand relaxed on the table surface.
Assesses central slip integrity of the extensor tendon at the PIP joint.
Grasp the proximal phalanx and stabilize the metacarpophalangeal joint in extension. Instruct the patient to actively extend the P.I.P. joint. If the patient is unable to actively extend the P.I.P. joint, an avulsion of the extensor tendon central slip is indicated. This represents a boutonniere deformity, which is characterized by hyperextension of the D.I.P. joint with the P.I.P. joint assuming a position of flexion. You should note that a similar deformity may occur from a pseudo boutonniere deformity which results from a flexion contracture of the P.I.P. due to volar capsule injury. A patient with a pseudo boutonniere deformity will be unable to extend the P.I.P. joint but will retain the ability to flex the D.I.P. joint. (Pause) When performing the boutonniere deformity test ask the patient to flex the D.I.P. joint while you maintain extension of the P.I.P. joint. If the patient cannot extend the P.I.P. joint but can actively flex the D.I.P. joint, a pseudo boutonniere deformity is indicated.
Mallet Finger Test
Position the patient with the forearm in pronation and the hand relaxed on the table surface.
Assesses extensor tendon integrity at the DIP joint.
Isolate the tendon by holding the involved finger at the middle phalanx. Begin with the D.I.P. joint relaxed in flexion. Instruct the patient to extend the D.I.P. joint. Inability to extend the D.I.P. joint is indicative of extensor tendon avulsion at its attachment on the base of the distal phalanx.
Flexor Digitorum Superficialis Test
Position the patient with the forearm in supination and the hand relaxed on the table surface.
Assesses flexor digitorum superficialis tendon function.
To isolate the involved tendon, hold the patient's fingers in extension, except for the one being tested. Then have the patient flex the involved finger at the P.I.P. joint. If the patient can actively flex the P.I.P. joint, the tendon is intact. If not, the tendon may be cut or ruptured
Flexor Digitorum Profundus Test
Position the patient with the forearm in supination and the hand relaxed on the table surface
Assesses flexor digitorum profundus tendon function.
Isolate the tendon by holding the patient's fingers in extension, except for the involved finger. You should further isolate the D.I.P. joint by maintaining the M.C.P. and P.I.P. joints of the affected finger in full extension. Then have the patient flex the finger in question at the D.I.P. joint. If the patient can actively flex the D.I.P. joint, the tendon is intact. If not, the tendon may be cut or ruptured.
Instruct the patient to flex both shoulders and elbows approximately 90 degrees. Then ask the patient to flex both wrists so that the dorsal surface of both hands can be placed against one another.
Detects carpal tunnel syndrome.
The patient should hold this maximally flexed position for at least one minute. After approximately one minute, tingling or numbness in the median nerve distribution over the involved palmar surface indicates the presence of carpal tunnel syndrome.
Pip & Dip Collateral Ligament Tests
(These tests may be repeated in similar fashions to assess the collateral stability of the Distal Interphalangeal Joints or D.I.P. Joints.)
Position the patient so that the pronated forearm and hand are supported in a relaxed position on the table.
Assesses the ulnar collateral ligaments of the finger joints
Grasp the medial and lateral aspect of the proximal phalanx with your thumb and index finger. Use the thumb and index finger of your other hand to grip the medial and lateral aspect of the intermediate phalanx. While stabilizing the proximal phalanx with one hand, maintain the joint in 15 to 20 degrees of flexion. Use your other hand to radially distract the intermediate phalanx which stresses the ulnar collateral ligament of the proximal interphalangeal joint. While applying the stress, visualize and feel for abnormal opening of the joint as compared to the uninvolved joint of the other hand. Normally, there should be a slight opening with a firm end point. The absence of a firm end point accompanied by associated sensations of pain or instability indicates a sprain of the ulnar collateral ligament.
(These tests may be repeated in similar fashions to assess the collateral stability of the Distal Interphalangeal Joints or D.I.P. Joints.)
Position the patient so that the pronated forearm and hand are supported in a relaxed position on the table.
Assesses the radial collateral ligaments of the finger joints
This same test may then be reversed by distracting the intermediate phalanx ulnarly to stress the radial collateral ligament. Again, maintain the joint in 15 to 20 degrees of flexion while stabilizing the proximal phalanx with one hand. Use the other hand to ulnarly distract the intermediate phalanx which stresses the radial collateral ligament of the proximal interphalangeal joint. While applying the stress, visualize and feel for abnormal opening of the joint as compared to the uninvolved joint of the other hand. Again, there should be a slight opening with a firm end point. The absence of a firm end point accompanied by associated sensations of pain or instability indicates a radial collateral ligament sprain.
MCP Collateral Ligament Test
Position the patient so that the pronated forearm and hand are supported in a relaxed position on the table surface. To enhance examination and visualization, ask the patient to slightly flex the uninvolved fingers further into flexion than the involved finger.
Assesses the ulnar collateral ligaments of the metacarpophalangeal joints.
For stabilization, you should grasp the distal aspect of the metacarpals. Use the thumb and index finger of your other hand to grip the medial and lateral aspect of the proximal phalanx and to maintain the joint in 30 degrees of flexion. Use your thumb and index finger to radially distract the proximal phalanx which stresses the ulnar collateral ligament of the metacarpophalangeal joint. While applying the stress, visualize and feel for abnormal opening of the joint as compared to the uninvolved joint of the other hand. Normally, there should be a slight opening with a firm end point. The absence of a firm end point accompanied by associated sensations of pain or instability indicate an ulnar collateral ligament sprain.
Position the patient so that the pronated forearm and hand are supported in a relaxed position on the table surface. To enhance examination and visualization, ask the patient to slightly flex the uninvolved fingers further into flexion than the involved finger.
Assesses the radial collateral ligaments of the metacarpophalangeal joints.
This same test may then be reversed by distracting the proximal phalanx ulnarly to stress the radial collateral ligament. Again maintain the joint in 30 degrees of flexion while stabilizing the metacarpals with one hand. Use your other hand to ulnarly distract the proximal phalanx which stresses the radial collateral ligament of the metacarpophalangeal joint. While applying the stress, visualize and feel for abnormal opening of the joint as compared to the uninvolved contralateral joint. Again, there should be a slight opening with a firm end point. A sprain of the radial collateral ligament is indicated by the absence of a firm end point accompanied by associated sensations of pain or instability.
Position the patient with the forearm in neutral and the hand supported in a relaxed position on the table surface.
Assesses ulnar collateral ligament stability at the thumb's metacarpophalangeal joint.
Grasp the medial and lateral aspect of the first metacarpal with your thumb and index finger. Use the thumb and index finger of your other hand to grip the medial and lateral aspect of the proximal phalanx, maintaining the joint in extension. Apply ulnar stress to the joint by abducting the proximal phalanx. While applying the stress, visualize and feel for abnormal opening of the joint as compared to the contralateral thumb. Normally, there should be a slight opening with a firm end point. The absence of a firm end point accompanied by associated sensations of pain or instability indicate a sprain of the ulnar collateral ligament.
Position the patient with the forearm in supination and the hand relaxed on the table surface.
Detects carpal tunnel syndrome.
Use your index finger to tap over the carpal tunnel at the wrist. A positive test results when the tapping causes tingling or paresthesia in the area of the median nerve distribution, which includes the thumb, index finger, and middle and lateral half of the ring finger. A positive Tinel's sign at the wrist indicates carpal tunnel syndrome.
Bunnel-Littler Test
Position the patient with the forearm in pronation and the hand relaxed on the table.
Evaluates the tightness of the hand's intrinsic muscles.
To perform the test, hold the metacarpophalangeal joint in a few degrees of extension and move the proximal interphalangeal joint into flexion. If, in this position, the P.I.P. joint can be flexed, the intrinsic muscles are not tight and are not limiting flexion.
Retinacular Test
Position the patient with the forearm in pronation and the hand relaxed on the table surface.
Verifies the tightness of the retinacular ligaments.
To conduct the test, hold the P.I.P. joint in full extension as you try to move the D.I.P. joint into flexion. If the joint does not flex, limitation is due to either contracture of the joint capsule or to retinacular tightness. To distinguish between these two, flex the proximal interphalangeal joint slightly to relax the retinaculum. If the distal interphalangeal joint then flexes, the retinacular ligaments are tight. If the joint does not flex, the distal interphalangeal joint capsule is probably contracted.
Allen Test
Instruct the athlete to make a tight fist and open it fully three or four times.
This test determines whether or not the radial and ulnar arteries are supplying the hand to their full capacities.
While the athlete is holding the last fist, the evaluator places compression on either the radial or ulnar artery. If upon release, blood fails to return to the palm and fingers, an obstruction to the artery's blood flow is possible.