Hand and Wrist Examination

FRCS Pg 42-49
Brachial Plexus Examination
• Differentiate pre or post ganglionic
• Look:
• Horner’s Syndrome
• Posture of limb (erb’s, klumpke’s)
• Power
• Rhomboids (DSN) -> if weak, pre ganglionic
• Sensation
• Check Dermatomes C5-T1
• Investigation
• Chest X-ray to look for Phrenic Nerve Palsy
Brachial Plexus Examination (2)
• Motor
• C5 – Deltoid
• C6 – Wrist Extensor
• C7 – Wrist Flexion
• C8 – Finger Flexor
• T1 - Intrinsic
 Peripheral Nerve Lesion
• Look
• Muscle wasting (1st dorsal interosseous,
thenar/hipothenar eminences)
• Nerve anterior n posterior interosseous
show no wasting in the hand
• Sensation
• Median, ulnar, radial
• Interosseus nerve lesion will have no
sensory loss
• Ulnar -> high or low lesion (check sensation
on dorsum hand)
• Ask to lift up hand -> if wrist drop -> PIN
• Ask to make OK sign -> if unable -> AIN
Peripheral Nerve injuries (Seddon)
• Neuropraxia
• Physiological, demyelination
• Axonotmesis
• Endoneural tube still in continuity,
wallerian degeneration
• Neurotmesis
• Epineurium divided, surgery treatment
• Sunderland Classification:
• Grade I-V
• III -> scarring endoneurium
• IV -> complete scarring
• Myotome
• Muscle mass supplied by a spinal nerve
• Dermatome
• Skin area supplied by a spinal nerve
• Erb’s palsy
• Long-standing traction palsy to upper trunk C5-6
• Arm internal rotated (suprascapular nerve)
• Elbow Extended
• Forearm pronated
• Wrist digits flexed
• Klumpke’s Palsy
• Claw hand, decreases sensation medial arm (C8 T1)
• Claw hand
• Combined median/ulnar nerve palsy, RA, Volkmann’s contracture
 Ulnar
• Memorandum 1
Nerve Lesion
• On inspection there is a well-healed longitudinal surgical scar over the
volar-ulnar aspect of the wrist. There is abduction of the little finger
and hypothenar muscle wasting.
• The attitude of the hand is suggestive of ulna claw hand with flexion of
the ring and Little finger PIP joints. The distal IP joints are also flexed,
suggesting that the FDP is intact.
• There is also hyperextension of -the MCP joints of the little and ring
fingers.
• There was no obvious skin ulceration, brittleness of the nails or tropic
changes. The nerve was tender when palpated just lateral to the FCU
tendon at the wrist; however, Tinel's test at the wrist for ulnar nerve
irritation was negative.
• There is decreased sensation at the ulnar border of the little finger but
normal sensation on the dorsum of the hand.'
• 'Can you stretch both arms out please?' 'On inspection there are no
obvious deformities such as cubitus valgus or varus suggestive of an old
elbow fracture.
• There are no obvious scars around the elbow, forearm and wrist.'
 Ulnar Nerve Lesion
• Memorandum 2
• 'Would you roll up your sleeves and place
your hands palm down on your lap/this
table please?' ·
• 'On inspecting the dorsal surface of the
hand there is marked interosseous muscle
wasting, particularly of the first dorsal
interosseous muscle, with hollowing of the
skin on the dorsal aspect of the first web
space.
• There is marked muscle wasting on the
medial side of the forearm and a cubitus
valgus deformity at the elbow.
• There are no obvious scars on the medial
side of the elbow that suggest previous
ulnar nerve decompression or other scars
of note.'
 Ulnar Nerve Lesion
• Palpation of the nerve
• Palpate the nerve at the elbow. Find the nerve
proximal to the tunnel. Flex and extend the
elbow looking and feeling for abnormal
mobility of the nerve behind the medial
epicondyle. Roll the nerve under your fingers
above the medial epicondyle and follow it until
it disappears into FCU.'
• 'Is it tender? Do you feel any numbness or
tingling in your hand when I tap on the nerve?
• 'There was obvious tenderness and thickening
of the nerve when palpated behind the medial
epicondyle of the elbow. Tinel's test at the
elbow was negative, as was the ulna nerve
hyperflexion test at the elbow.'
Ulnar Nerve Lesion
• Sensation
• 'I would now like to test for
sensation. Can you feel me
touch you here? Here and now
here? Does it feel the same as
here on the other hand?‘
 Ulnar Nerve Lesion
• Motor function
• Palmar interossei : Card test
• 'Hold your hand out. Palm down, fingers together please.
I'm just going to slide this ca rd between your fingers
(middle and index). Keep your fingers straight. Can you
grip the card between your fingers and stop me pulling it
out? Now between your middle and ring fingers and
finally ring finger and little finger.'
• In the case of weak palmar interossei it is easy to pull the
card out.
• Dorsal interossei
• 'Can you spread your fingers, please, and stop me pushing
them together?‘
• First dorsal interosseous muscle While feeling the first Dl,
place the index finger into abduction. Ask the patient to
keep the index finger still while you try to adduct the
index finger. Feel for the muscle bulk and contracture .
Ulnar Nerve Lesion
• Abductor digiti minimi
• 'Now push your little finger out
against my finger'
• Test for power but also feel the
bulk of ADM while it contracts.
• Or
• 'Can you push your little fingers
together?' (More sensitive test.)
• FDP little finger (Pollock's test)
• If FDP weak, nerve abnormality at
elbow (high lesion).
 Ulnar Nerve Lesion
• Froment's test (book test)
• 'Finally I would like to perform Froment's test for
adductor pollicis.' 'Could you grab hold of this sheet
of paper with your thumb on top of it holding it
against/he side of your index finger? Now stop me
pulling the paper away.'
• Look for flexion of the IP joint of the thumb. This
indicates that FPL (supplied by the median nerve) is
compensating for a weakened adductor pollicis. This
becomes more pronounced if the examiner tries to
pull out the sheet while the patient tries to hold it.
• Flexor carpi ulnaris
• Resistance is felt in the tendon when allempting to
extend the wrist (with the wrist flexed and ulna
deviated).
Ulnar Nerve Lesion
• Differential diagnosis
• • Cervical radiculopathy
• • Thoracic outlet syndrome
• • Cervical rib
• • Cervical spondylosis
• • Pancoast's tumour
• • Benediction hand versus claw hand.
 Sites of Ulnar Nerve compression neuropathy
• Arcade of Struthers
• Formed by superficial muscle fibres of
the medial head of triceps attaching to
the medial epicondylar ridge by a
thickened condensation of fascia
• Cubital tunnel
• Formed by fascia from the medial
epicondyle to the olecranon (thickened
Osborne's ligament)
• Fascia of FCU
• Fascial bands connecting the two heads
of FCU
• Deep flexor pronator aponeurosis
• Exit of the ulnar nerve from FCU
Causes of ulnar nerve palsy (proximal- distal)
Brachial plexus
• Trauma.
At the elbow
•Bony abnormalities: osteophytes, bony spurs, cubitus valgus
• Scarring
• Anomalous muscles (anconeus epitrochlearis muscle)
• Tumours
• Ganglions
• Trauma: old fractures (medial epicondyle non-union), lacerations.
At the wrist
• Lacerations
• Ganglia.
Ulnar tunnel syndrome (rare)
• Ulnar nerve compression in Guyon's canal.
• Signs of distal ulnar nerve lesion (low lesion)
• • Sensation of the ulnar side of the dorsum of the hand intact
• • FCU intact
• • No muscle wasting of forearm
• • Ulnar half of FDP intact {ulnar paradox), clawing
• • Wartenberg's sign (loss of third palmar interosseous), wasting of the
hypothenar eminence, guttering of the dorsal interosseous, scar cubital fossa
or Guyon's canal
• • Tender over Guyon's canal
• • Decreased sensation in ulnar 1 ½ digits (sensation of the dorsum of the
hand preserved).
Wartenberg's sign
• Wartenberg's Sign
• the slightly greater abduction of
the fifth digit, due to paralysis
of the abducting palmar
interosseous muscle and
unopposed action of the radial
innervated extensor muscles
(digiti minimi, digitorum
communis
Ulnar tunnel syndrome
• Functional loss distal ulnar nerve lesion
• Loss of stable pinch between the thumb and index finger with hyperextension
deformities at the MCP joints and compensatory flexion deformity of the IP
joints causing finger clawing.
Ulnar tunnel syndrome
Tendon transfers for a distal ulnar nerve
• I. For weak pinch between the thumb and index finger (thumb
adduction and index finger abduction)
• • Split insertion of middle finger FDS to adductor pollicis
• • EIP to first DI muscle
• 2. For loss of the interossei and ulnar two lumbricals (clawing hand)
• • Zancolli capsulodesis to stabilize the MCP joint, in which the superficial is
tendon is looped volar to the A1 pulley and sutured through itself to produce
20° flexion MCP joints
• • Or split tendon transfers of FDS ± ElP to the radial dorsal extensor
apparatus. Carried out to restore MCP joint flexion and IP joint extension.
Radial nerve palsy
• Radial nerve palsy, a classic short case.
• Memorandum
• 'Would you roll up your sleeves and stretch your arms out in front of you
please?‘
• 'On inspection there is an obvious left wrist drop. There is gross wasting of
the left forearm muscles. There does not appear to be any gross wasting of
the triceps muscle. There are no obvious scars or swellings visible. I would
now like to test the motor function of the radial nerve.‘
• Extensors of the wrist
• Place patient's wrist in extension. 'Don 't let me pull it down.' ' I am testing
the extensor muscles of the wrist. He has weakness of wrist extension MRC
grade 4 minus.
 Radial nerve palsy
• Extensors of the fingers
• 'Can you bend your elbow into your side and
give me your hand facing down (palm down)? I
will support your wrist. Can you try to straighten
your fingers please? Straighten them. Don't let
me push them down.'
• ' He is able to extend his IP joints because of the
action of his interossei and lumbrical muscles.
He is, however, unable to straighten his MCP
joints.‘
• Test EPL
• 'Please place your palm flat on tire table. Can
you lift up your thumb?' Tests retropulsion.
Radial nerve palsy
• Test supinator
• Elbow must be extended (nerve compression against middle third of
humerus). 'Now straighten your elbow. Can you tum your hand over (against
me)? Don't let me stop you.' 'I am testing the supinator muscle.
Radial nerve palsy
• Test brachioradialis
• Flex the elbow in the mid prone position (nerve compressed against middle
third of humerus).
• 'Can you bend your elbow?' 'I am now testing brachioradialis muscle.
 Radial nerve palsy
• Test triceps
• Extend the shoulder. 'Can you straighten your
elbow?' (Gravity excluded)
Test resistance.
Test triceps reflex. 'He has normal triceps
power and no loss of his triceps reflex.
Weakness of the supinator and brachioradialis
muscle suggests a lesion above the supinator
tunnel. Weakness of the triceps suggests a
lesion at or above the midhumerus.'
Radial nerve palsy
• Sensation
• 'There is sensory loss over
the first dorsal interosseous
muscle (anatomical snuff
box).
• 'This patient has features
suggestive of low/high
radial nerve palsy.
 Radial nerve versus PIN palsy
• Radial nerve
• • Inability to extend elbow, supinate
forearm, wrist drop
• • Diminished sensation over first dorsal
interosseous muscle (just over the
anatomical snuffbox).
• PIN
• • Nerve supply to ECRL and
brachioradialis intact
• • Able to supinate and extend wrist (with
radial deviation)
• • Unable to extend MCP joints
• • No sensory loss
 Causes of a radial nerve palsy
• Axilla
• • Saturday night palsy: neuropraxia from prolonged
local pressure
• • Ill-fitting crutches.
• Mid humerus
• • Fracture of the shaft of the humerus
• • Tourniquet palsies
• • Lacerations, gunshot wounds.
• At and below the elbow
• • Entrapment syndromes (FREAS; a mnemonic for
fibrous tissue bands, radial recurrent vessels, fibrous
edge of ECRB, arcade of Frohse, supinator)
• • Rheumatoid elbow
• • Dislocated elbow
• • Monteggia fracture
• • Surgical resection of the head of the radius
• • Mass lesions (ganglions).
Tendon transfer (Jones transfer)
• • Wrist extension: pronator
teres to ECRB
• • MCP joint extension: FCR
(through interosseous
membrane) or FCU (around
ulna) to EDC
• • Extension and abduction
thumb: palmaris longus to EPL.
Causes of a radial nerve palsy
• Supinator tunnel
• The fibres of the supinator muscle are
arranged in two planes, between
which the deep branch of the radial
nerve lies (PIN). The supinator arises
from the lateral epicondyle of the
humerus, the elbow joint and
superior radial ulnar joint and the
supinator crest and fossa of the ulna.
It inserts into the posterior, lateral
and anterior aspects of the neck and
shaft of the radius as far as the
oblique line.
Carpal tunnel syndrome
• History
• • Age
• • Hand dominance
• • Numbness
• • Pins and needles
• • Night symptoms
• • Clumsiness
• • Diabetes, hypothyroid, neck symptoms
• • Occupation.
Carpal Tunnel Syndrome
• Examination
• • Routine hand examination with
particular attention to:
• • Muscle wasting
• • Sensory deficit
• • Motor deficit
• • Decreased sweating
• • Ulnar nerve signs
• • Provocative tests: Tinel's sign,
Phalen's sign, median nerve
compression test.
Video
 Carpal Tunnel Syndrome
• Signs
• Wasting thenar eminence (LOAF: mnemonic for lateral
two lumbricals, opponens pollicis, abductor pollicis
brevis, flexor pollicis brevis)
• Decreased sweating and increased temperature at the
thenar eminence
• Decreased sensation in the radial 3 1/2 digits (palmar
branch proximal to tunnel)
• Reduced power APB
• Carpal compression (Durkin's test) - most sensitive.

Test Sensitivity (%) Specificity (%)

Tinnnel's 74 91
Phalen's 61 83
CTS - Causes
• Can be congenital or acquired. Majority of cases are idiopathic.

• Congenital
• • Persistent median artery (thrombosis of such an artery can cause an acute onset of
carpal tunnel synd rome)
• • High origin of lumbrical muscles.
• Acquired
• • Inflammatory: synovitis, rheumatoid arthritis, gout
• • Traumatic: Colles' fracture
• • Fluid retention: pregnancy, renal failure, myxoedema, diabetes, congestive cardiac
failure, steroids
• • Space-occupying lesion: lipoma, ganglion.
CTS – Differential Diagnosis
• • Cervical radiculopathy
• • Collagen vascular disorders
• • Thoracic outlet syndrome
• • Raynaud's disease
• • RSD (Reflex Symphatetic Distrophy)
• • Spinal cord lesions - tumour, syrinx
• • Peripheral neuropathy: alcohol, diabetes.
 Median nerve
• Memorandum 1
• On inspection of the left hand there is obvious thenar muscle
wasting. The thumb appears to be lying in the plane of the
palm - a simian thumb (ape-thumb deformity).
• There is atrophy of the pulp of the index and main fingers,
dystrophic nail changes present, generalized nicotine-stained
fingers and possibly a cigarette burn over the radial border of
the distal phalanx of the index finger.
• There is no obvious ulceration seen in the hand or fingers
and no visible scars are present.'
• 'The thumb cannot be apposed to the fingertips to produce
useful function. Testing for APB revealed MRC power grade 4
minus compared to the opposite normal side with reduced
muscle bulk and tone present. However, testing for FPL
revealed normal power.'
 Median nerve
• Memorandum 2 (higher lesion)
• 'In addition, there is wasting of the left forearm.
The index finger is held in a position of extension
- benediction attitude. On asking the patient to
make a fist the index finger remains pointed -
finger pointing sign.‘
• 'I would now like to test for sensation.' 'Can you
feel me touch you here? Here? Does it feel the
same as here on the other hand?' 'There is
sensory loss over the palmar aspects of the
lateral 3 ½ digits and thenar eminence.‘
• 'I would now like to test for power.' 'Lay your
hand on the table, palm up please. '
 Median nerve
• Abductor pollicis brevis
• 'I am going to hold your wrist so you don't move
your hand. Now lift your thumb up off the table to
touch my finger. Push against it.
• Flexor pollicis longus
• 'Now can I hold your thumb and ask you just to
wiggle the tip of it.
• Proximal phalanx is kept steady by the examiner.
• Flexor digitorum superficialis
• 'There is also loss of flexion at the index and middle
fingers.'
• Pronator teres
• 'I am going to hold your hand like a handshake. Now
can you twist against my hand while I feel your
forearm '
• Hold the patient's hand and resist as they try to
pronate the forearm.
Median nerve
• Low nerve lesion
• • Loss of APB and variable loss of FPB (and
opponens pollicis)
• • Weakness of thumb abduction and
opposition.
• High nerve lesion
• Low lesion plus:
• • Loss of flexion IP joint thumb (FPL)
• • Loss of flexion index and middle fingers (FDS, FDP)
• • FCR.
 Median Nerve
• Tendon transfers for low lesion
• For thumb opposition (loss of APB)
• • Ring finger FDS transfer to APB, or EIP
to APB
• • MCP ± JP joint fusion.
• Tendon transfer for high lesion
• For index and middle finger flexion
• • FDP index and middle finger sutured
side-to-side (tenodesed) to the
neighbouring intact FDP of the ring and
little fingers (FDS cannot be used, as it is
supplied by the median nerve).
• For flexion IP joint thumb
• • Brachioradialis to FPL.
• For thumb opposition
• • EIP to APB.
Causes of a median nerve palsy
• At the elbow
• • Fractures
• • Elbow dislocations
• Distal to the elbow
• • Pronator entrapment syndromes.
• In the forearm
• • Lacerations
• • Gunshot wounds
• • Forearm bone fractures.
• Wrist
• • Especially lacerations
• • Colles' fractures
• • Carpal tunnel syndrome.
 Pronator syndrome Entrapment
• Pronator syndrome Entrapment of the median
nerve around the elbow.
• History
• • Ache or discomfort of the forearm after heavy use
• • Weakness or clumsiness of the hand
• • Paraesthesia in all or part of the median nerve.
• Examination
• • Local tenderness to deep compression with
reproduction of symptoms
• • Tinel's sign is negative at the wrist but may be
positive at the proximal anterior aspect of the
forearm
• • Negative Phalen's
• • Weakness of thenar muscles but sparing of AIN-
innervated muscles.
 Pronator syndrome Entrapment
• Provocation tests
• • Resist elbow flexion with forearm supinated
(bicipital aponeurosis)
• • Resist forearm pronation with elbow
extended (two heads of pronator teres) "
• • Isolate long finger PIP joint flexion (FDS
origin).
• Sites of compression (four sites)
• • Supracondylar process humerus (ligament
of Struthers)
• • Bicipital aponeurosis
• • Between heads of pronator teres
• • Proximal arch of FDS
 EPL rupture
• Classic short case: either a rheumatoid
patient or post-Colles' fracture. A traumatic
laceration is unlikely.

• Memorandum
• 'On inspection we have a middle-aged
woman with a generalized soft-tissue
swelling over the right wrist joint. There is
also a deformed appearance of the wrist
suggestive of a recent fracture. The attitude
of the right thumb is one of flexion at the IP
joint.
 EPL Rupture
• Active dorsiflexion of the wrist is reduced
to 30deg compared to almost 80 deg on
the opposite normal side.
• palmar flexion of the wrist was 50deg
compared to 70deg on the opposite side.
Pronation and supination are essentially
normal.
• There was no active extension of the right
thumb, suggestive of EPL rupture.
• No contracture of the EPL tendon. There
was some mild swelling and tenderness
around the dorsal radial surface of the
wrist in the line of the EPL tendon and a
suggestion of a gap present along this
tendon.‘
 EPL Rupture - Management
• EIP to EPL tendon transfer. Requires a
GA and the patient will need a thumb
outrigger splint for 4 weeks
postoperatively.
• Three incisions
• • Transverse over metacarpal head index
finger (EIP ulnar to EDC)
• • Transverse incision just proximal to
extensor retinaculum
• • Oblique incision at the base of the thumb
to identify EPL distal to rupture.
Terima Kasih