Wrist and Hand: 

 

Location of pain -

• Details should be gained in order to separate symptoms of wrist and hand from elbow or upper arm. 

• Trauma to cervical spine can cause pain to travel down to hand. 

•  Injury to median , ulnar, or radial nerve will also be felt in specific areas of the hand. 

        Questions:

          *Where exactly is the pain radiating from, what specific part of your wrist or hand?

          *What type of structure do you feel is injured? Do you feel it is deep or superficial to the skin?

Mechanism of injury -

• Identifying the MOI can help to localize where the pain is coming from.

• Ask questions about how the injury happend and what kind of posture the patient was in.             

• Video of broken wrist:  MOI: Broken wrist

          Questions:

          *What happened?

          *How did you fall or land when injuring yourself?

          *Did you try and brace you fall, such as outstretching your arm?

Relevant sounds or sensations - 

• Many injuries have sounds or sensations that accompany them. 

• Ask questions related to what the patient felt or heard at onset of trauma. 

• Pay close attention to snapping or popping noises. 

           Questions:

            *Did you hear a pop, or crack?

            *What did you initially feel when this happened? 

            *Was the pain sharp or dull?  Did you feel any tingling sensations or any numbness?

            *On a scale of 1-10 how much pain are you experiencing?

Duration of symptoms - 

• Notice the time period of pain in the patient. 

• Nagging or prolonged pain in the wrist can represent a sprain or a scaphoid fracture. 

         Questions:

            *How long have you been having symptoms of pain?

            *How was the initial pain compared to now?

Description of symptoms - 

• Ask patient to describe type of pain. 

• Burning pain versus aching pain can result in different injuries and are helpful in diagnosis.

            Questions:

             *Is the pain that you are experiencing constant, or does if hurt during certain movements or activities?

             *What type of pain are you experiencing now?  Is the pain it sharp, dull, or an aching feeling?

Previous history -

• Ask questions about previous history to decide what kind of problems the patient has had in the past. 

• Allows you to make a more accurate decision about the injury. 

           Questions:

            *Have you previously injured your wrist or hand before?

            *How was the injury treated previously, and how long ago was your injury?

            *What type of medications did you use to treat your symptoms?

General medical health -

• Having knowledge about the person's overall health is important when trying to come to a diagnosis for a patient. 

• Be sure you know what kinds of medication the patient is on and how they react to certain drugs. 

       Questions:

            *Do you have any allergies to any medications?

 

 

Elbow: 

It is important to find the cause and affect relationship between the mechanism of injury and the onset of the symptoms to help create a successful treatment plan. Also, because the elbow may be the site of referred pain from the cervical spine, all other possible sources of pain must be ruled out. 

**The questions found in the wrist and hand section above will also be asked for injuries of the elbow.**

 

Location of the symptoms-

·         First check the patient by localizing the area of pain, the type of pain, and any dysfunction occurring. (note that possibility of these symptoms may be referred by pathology proximal or distal to the elbow)

·         Referred pain usually presents with symptoms localized within the distribution of a specific nerve or root   

 

Onset of the symptoms-

·         Elbow pain may have an acute or chronic onset.

·         Chronic conditions of the elbow can initially produce minor symptoms related to activity that progressively worsen to constant pain during normal activity.

Mechanism of injury (MOI)-

·         The elbow can be acutely injured by high stress generated by throwing or weight lifting, or if the hand is planted on the ground so it is away from the side of body and forces are transmitted across the joint (MOI: Dislocated elbow).

·         Most elbow injuries are caused by repetitive low-load stress

o        Question athletes involved in throwing activities about the level of activity, including the number of throws, time span the throws occur in, and any changes in throwing technique.

o        Throwing a ball or using a racquet can cause stresses that result in tendinitis or neuritis in the elbow.

o        Adolescents are vulnerable to these injuries at open growth plates as stresses are transmitted across these areas.

o        Using computers, musical instruments, or machinery requiring repetitive wrist and finger motions may also produce or exacerbate current symptoms.

Technique-

·         Suspicions of improper technique, poor elbow biomechanics, or weak muscles commonly arise with overuse injuries.

·         Ask the patient about changes in technique ore equipment, or increases in the intensity or duration of play.

·         Questions regarding biomechanics may require the examiner to work with the athlete and coach in further evaluating technique and making necessary corrections.

Associated sounds and sensations-

·         Chronic clicking, locking, or popping of an elbow during movement may indicate Osteochondritis dessicans or an unstable joint. (the presence of these structures may be confirmed through diagnostic imaging)

Previous history-

·         Pain associated with seasonal activity may be related to poor training.

·         Due to the possibility of referred pain, patients with nontraumatic origin of pain or patients suspected of having referred pain from the cervical spine require investigation about a history of previous trauma, paresthesia, strength loss, or other dysfunction in this area.

General medical health-

·         It is necessary to obtain a history of other medical conditions.

·         Certain vascular problems, neurologic involvement, or systemic diseases may predispose the elbow to inflammatory or degenerative injuries or illnesses

 

 

**Information for the Palpation section was derived from the following:

    - Chad Starkey and Jeff Ryan. Evaluation of Orthopedic and Athletic Injuries 2nd Edition. Pages 497-498 (elbow), 529-530 (hand). Copyright 2002 F.A. Davis Company.

 

 

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Observation

 

Elbow and Forearm:

Check the upper arm, elbow, and forearm for evidence of contusions, ecchymosis, scars, or swelling.

 

Anterior Structures	Medial Structures	Lateral Structure	Posterior Structures
Carrying Angle- With the elbow fully extended and the forearm supinated, Note: the presence of an increased carrying angle (cubitus valgus) or a decreased carrying angle (cubitus varus). Cubitus valgus can occur in baseball pitchers due to repeated valgus loading during the throwing motion. Fracture of one or more bones or their epiphyseal plates can also result in changes in the carrying angle. http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/ mo77_dumontier/index_us.shtml	Medial epicondyle- With excessive swelling,  the medial epicondyle may be less visible (even as the most prominent structure on the medial aspect of the elbow).	Alignment of the wrist and forearm- the wrist should be centered on the forearm, if it is not centered, there can be compression of structures such as the radial nerve. Drop wrist syndrome can create an inability to extend the wrist.	Bony alignment- When the elbow is flexed to 90 degrees,the medial and lateral epicondyle, and the olecranon process form an isosceles triangle; when the elbow is extended, they typically lie in a straight line, deviations from these alignments are a possible result of a bony pathology.   http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/ mo77_dumontier/index_us.shtml
Cubital fossa- Check for swelling within the cubital fossa which can place pressure on the local neurovascular structures possibly due to injury to nearby soft tissues (ie. distal biceps tendon). The brachial artery and its two subdivisions (radial/ulnar), medial nerve and musculotaneous nerve all pass through this fossa. http://www.dartmouth.edu/~anatomy/elbow/surface/surface1.html	Flexor muscle mass (wad)- Visible along the medial aspect of the elbow and forearm flexor muscle mass widens about 2 to 3 inches below the elbow. Prolonged immobilization or disuse from long-term tendonitis may cause a loss of girth along the medial forearm.	Cubital recurvatum- the alignemt of the forearm and humerus when the elbow is fully extended is normally a straight line extension beyond 0 degrees (cubital recruvatum) is common, especially in women	Olecranon process and bursa- The bony contour of the olecranon process is visible when the elbow is flexed. The outline of the olecranon can be masked due to acute injury or overuse conditions causing the rupture, swelling, or inflammation of the Olecranon bursa.   http://medicine.ucsd.edu/clinicalmed/Joints4.html
		Extensor muscle mass (wad)- Visible along the lateral aspect of the elbow and forearm, the extensor muscle mass widens about 1 to 2 inches below the elbow. Prolonged immobilization or disuse after long-term tendinitis or radial nerve involvement can result in a loss of girth along the lateral forearm.

 

 

Wrist and Hand:

General	Wrist and Hand	Thumb and Fingers
Posture of the hand- when relaxed, the natural posture of the hand is in slight flexion, with a slight arch in the palm. If the arch is absent it may indicate an avulsion of one or more finger flexors, nerve pathology, or atrophy of the hand's intrinsic muscles (in the case of chronic injuries). link to pathological finger postures	Continuity of the distal radius and ulna- observe the symmetry of the distal radius and ulna for possible indication of a fracture with loss of continuity.	Skin and Fingernails- check for discoloration and changes in hair patterns or skin and nail texture (possibly indicating peripheral vascular disease, reflex sympathetic dystrophy, or Raynaud's phenomenon), clubbing or cyanosis of the nail (may indicate pulmonary disease, marfan syndrome, cardiovascular disorder, or other disease states). Also check for Subungual hematoma, Felon, or Paronychia.
Gross Deformity- Note any swelling, discoloration, or gross deformity. Dislocation of the MCP or IP joints results in obvious deformity of the joint's articulating surfaces. A fracture of the metacarpals shows a protrusion or depression along the usually flat dorsal surface of the hand.	Continuity of carpals and metacarpals- observe the metacarpal shafts for gross discontinuity observe area overlying the lunate for abnormal contour indicating dislocation.	Alignment of fingernails- the lateral four fingernails usually align during finger flexion if a finger deviates from the rest it could be a result of a spiral fracture of a phalanx or metacarpal.
Palmar Creases- Swelling in one or more of the compartments of the hand can obliterate the normal palmar creases.	Alignment of MCP joints- Compare MCP joint alignment relative to noninvolved side a depressed or shortened knuckle may indicate a metacarpal fracture.	Finger deformities- Irregular posture of one finger may indicate an acute injury or prevoius trauma. Deformities at the joint indicate a dislocation; deformities along the shaft of the bone may indicate a fracture.
Areas of cuts or scars- the tendons of the wrist and hand are superficial, making them vulnerable to even minor cuts. Check for Russel's Sign or paresthesia (feeling of pins and needles result of damage from acute or prior lacerations or previous surgeries) in one or more fingers.	Posture of the wrist and hands- Note the posture of the wrist and hand for any abnormalities possibly from trauma to structures between the cervical spine and wrist  (ie. Volkmann's ischemic contracture or Drop wrist syndrome).
	Ganglion cyst- check for collection of fluid or formation of a mass and pain caused by motion and tenderness to touch.

 

**Information for the observations section was derived from the following:

    - Chad Starkey and Jeff Ryan. Evaluation of Orthopedic and Athletic Injuries 2nd Edition. Pages 499 (elbow), 530-533 (hand). Copyright 2002 F.A. Davis Company.

 

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Palpation

 

 

Elbow and Forearm:

Anterior Structures	Biceps Brachii	The muscle belly can be palpated along the anterior aspect of the humerus until its tendon inserts onto the radius. The tendon is more easily recognized if the elbow is flexed 90 degrees.
	Brachioradialis	With the forearm in neutral position, resisted elbow flexion will allow palpation of the length of the brachioradialis from its attachment on th elateral supracondylar ridge to the distal attachment on the radial styloid process.
	Flexor-Pronator wad	Separated from the extensor wad by the posterior border of the ulna, the flexor-pronator wad can be felt by pressing the thumb into the cubital fossa to feel the muscle mass.
Medial Structures	Medial Epicondyle	Found on distal aspect of humerus medially as it flares away from shaft of bone. Palpation of this epiconlyle is tender in the presence of medial epicondylitis, but tenderness is also possible in an uninjured elbow.
	Ulna	The base of the ulna can be palpated distal to the elbow's medial joint space. The shaft is prominent throughout its length, especially along its medial and posterior surfaces; the posterior border can be palpated distally from the olecranon along its entire length. The anterior aspcet of the shaft can be palpated along the distal 2/3 of its length as it arises from beneath the flexor-pronator wad to its articulation with the wrist.
Lateral Structures	Lateral Epicondyle	Found on most distal lateral aspect of humerus, projecting laterally. Palpate for tenderness caused by inflammation at the origin of the wrist extensors, however, it is also possible to have tenderness in the epicondyle without injure.
	Radial Head	Palpate slightly distal from the lateral joint line underneath the posterior aspect of the wrist extensor muscles. If palpated during wrist pronation and supination, the radial head is felt to roll beneath the finger.
	Radius	The lateral surface of the distal half of the radiuscan be easily palpated, along with the radial head (see above) and styloid process (see below).
Posterior Structures	Triceps Brachii	With the elbow slightly extended, the tendon of the triceps brachii can be palpated from its attachment at the olecranon. The medial head is palpated over the medial aspect of the distal humerus, the posterolateral portion is formed by the lateral head of the triceps, and the posteromedial portion is formed by the long head.
	Olecranon Process	Palpate from the ulna to the prominent rounded area on the posterior aspect of the elbow, palpate for tenderness and mobility.
	Extensor wad	The extensor wad can be grasped between the cubital fossa and the lateral epicondyle and palpated distally.

 

 

 

Hand:

                                                           

Metacarpals	All five metacarpals are palpable along their entire length, beginning at the MCP joint and proceeding proximally to the CMC joints, note for areas of pain, deformity, or crepitation. The heads of the metacarpals can be felt by making a fist causing the knuckles to become visible.
Phalanges	For each phalanx palpate distally from the MCP joint and follow from the proximal to middle to distal phalanx. The thumb will only have a proximal and distal phalanx. Note each phalanx for pain, crepitus, or deformity (pay close attention to find fractures along the flares adjoining the bases or heads with shafts)
Thenar Compartment	Thenar muscles (abductor pollicis brevis, flexor pollicis brevis, and opponens pollicis) make up the thenar compartmen, the soft tissue found lateral to the septum of the palmar aponeurosis.
Hypothenar Compartment	On the medial border of the hand, similar to the thenar compartment, the hypothenar compartment (made of hypothenar muscles) is the soft tissue found medial to the fibrous septum extending from the medial border of the palmar aponeurosis.
Ulnar Styloid Process	Palpate on the distal posteromedial border of the ulna for the styloid process, noting any tenderness or crepitus. Should be located 1cm proximal to radial styloid process.
Radial Styloid Process	Can be palpated on most distal aspect of the lateral radius, more easily when the hand is supinated, relaxing the tendons covering it.
Lister's Tubercle of Radius	Can be palpated on the dorsal surface of the distal radius

 

 

 

Carpals:

 

                                                                 

Label/ Pneumonic	Carpal Bone	Palpations
1 Some	Scaphoid	Comprises floor of  "anatomical snuffbox." This is a good starting point for the palpation of the carpals. Actively extend the thumb and first metacarpal making the
2 Lovers	Lunate	From the scaphoid bone, move toward the ulna and the lunate should be prominent across the joint line from the medial radial head, in line with the third metacarpal. This can be found following distally from Lister's tubercle of the radius on the dorsal aspect of the hand (see image below).
3 Try	Triquetrum	Palpate along most proximal aspect of the hand approximately one finger's breadth distal to the unlar styloid process.
4 Positions	Pisiform	Found directly anterior to triquetrum. Pisiform is prominent as the small, round protuberance on the most proximal and medial aspect of the palmar side of the hand when the hand is in anatomical postition.
5 That	Trapezium	Found between scaphoid and the thumb's metacarpal in the floor of the anatomical snuff box.
6 They	Trapezoid	Found at the base of the 2nd metacarpal, more easily palpated on the dorsal aspect of the hand.
7 Can't	Capitate	On the palmar side of the hand palpate from the hamate, following toward the thumb side of the hand, finding the capitate proximal the the base of the 3rd metacarpal. The capitate can also be found on the dorsal side of the hand following distally from Lister's tubercle, between the lunate and  the base of the 3rd metacarpal.
8 Handle	Hamate	Palpate the hook of the hamate on the palm moving inferiolateral from the pisiform (see image below). When the hand is in anatomical position, the hamate is found immediately across the joint line from the center of the ulna and distal to the pisiform.

 

Finding the Pisiform and Hook of the Hamate:                                                                          Palpating the Lunate, Capitate, and 3rd metacarpal:

**Information for the Palpation section was derived from the following:

    - Chad Starkey and Jeff Ryan. Evaluation of Orthopedic and Athletic Injuries 2nd Edition. Pages 501-502 (elbow), 536-537 (hand). Copyright 2002 F.A. Davis Company.

    - Keith L. Moore and Arthur F. Dalley. Clinically Oriented Anatomy 5th Edition. Pages 845-847 (hand), 799-800 (elbow). Copyright 2006 Lippincott Williams and Wilkins.

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