Comprehensive Guide to Hand and Wrist Examination for Healthcare Professionals

Hand and wrist examinations are essential skills for medical students and healthcare professionals, providing critical information about a patient's musculoskeletal and neurological health. Mastery of these techniques can lead to accurate diagnoses and effective treatment plans. This article delves into the nuances of hand and wrist examination, offering a step-by-step guide tailored to both beginners and seasoned practitioners.

1. Introduction to Hand and Wrist Anatomy

Understanding the anatomy of the hand and wrist is foundational for a thorough examination. The hand is composed of 27 bones, including the phalanges, metacarpals, and carpals, connected by a complex network of ligaments, tendons, and muscles. The wrist comprises eight carpal bones arranged in two rows, forming a crucial junction between the forearm and the hand. Key structures to consider during examination include:

• Carpal Bones: Scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, and hamate.
• Metacarpal Bones: The five bones that connect the wrist to the phalanges.
• Phalanges: The bones of the fingers, each finger having three (proximal, middle, and distal), except for the thumb, which has two.
• Tendons and Ligaments: Flexor and extensor tendons, along with collateral ligaments, provide movement and stability.

A thorough grasp of this anatomy will enhance the accuracy and effectiveness of your examination.

2. Preparation for the Examination

Before beginning the examination, ensure the patient is comfortable and relaxed. Here are some preparatory steps:

• Introduce Yourself: Always introduce yourself and explain the purpose of the examination to the patient.
• Obtain Consent: Make sure you have the patient’s consent before proceeding.
• Wash Your Hands: Hygiene is paramount; wash your hands thoroughly before touching the patient.
• Patient Positioning: The patient should be seated comfortably with their arm supported on a table at a level close to your own.
• Inspection Tools: Have necessary tools on hand, such as a tape measure, goniometer, and reflex hammer.

3. Visual Inspection

Begin the examination with a careful visual inspection, which can reveal much about the underlying conditions. Key aspects to observe include:

• Symmetry: Compare both hands for symmetry in size, shape, and muscle bulk. Asymmetry may indicate muscle wasting or swelling.
• Skin Condition: Look for any changes in skin color, texture, scars, or lesions. Cyanosis, pallor, or erythema may indicate vascular or inflammatory conditions.
• Deformities: Note any obvious deformities such as ulnar deviation, swan neck deformity, or boutonniere deformity, which are commonly associated with rheumatoid arthritis.
• Nail Changes: Examine the nails for pitting, clubbing, or discoloration, which may suggest systemic diseases such as psoriasis or endocarditis.

4. Palpation

Palpation follows inspection and provides vital information about tenderness, temperature, and texture. The sequence of palpation should follow a structured approach:

• Dorsal Aspect of the Hand and Wrist: Start palpating the dorsal aspect, including the metacarpals, phalanges, and knuckles. Check for tenderness or bony abnormalities.
• Palmar Aspect: Palpate the carpal bones, metacarpal heads, and thenar and hypothenar eminences. Look for tenderness, swelling, or nodules.
• Wrist Joint: Palpate the wrist joint and carpal bones for tenderness, especially over the scaphoid and lunate bones, which are prone to fractures.
• Temperature: Use the back of your hand to assess temperature differences between the affected and unaffected hand, which could indicate inflammation or infection.

5. Range of Motion (ROM) Assessment

Assessing the range of motion (ROM) is crucial for evaluating the functional capacity of the hand and wrist. ROM should be tested both actively (by the patient) and passively (by the examiner):

• Wrist Movements:
  • Flexion and Extension: Ask the patient to flex and extend the wrist. Normal wrist flexion is about 80 degrees, and extension is about 70 degrees.
  • Radial and Ulnar Deviation: The patient should move their wrist side to side. Normal radial deviation is about 20 degrees, and ulnar deviation is about 30 degrees.
• Finger Movements:
  • Flexion and Extension: The patient should make a fist (flexion) and then fully extend their fingers.
  • Abduction and Adduction: Ask the patient to spread their fingers apart (abduction) and bring them back together (adduction).
  • Thumb Movements: Assess thumb flexion, extension, abduction, adduction, and opposition.

Any restriction or pain during these movements can indicate conditions such as arthritis, tendinitis, or ligamentous injuries.

6. Strength Testing

Testing the strength of the hand and wrist muscles provides insight into neurological and muscular function:

• Grip Strength: Ask the patient to squeeze your fingers as hard as possible. Compare the strength bilaterally. Reduced grip strength can be a sign of conditions like carpal tunnel syndrome or nerve injury.
• Thumb Opposition Strength: Have the patient oppose their thumb to the little finger while you try to pull the thumb away. Weakness here may indicate median nerve dysfunction.
• Finger Abduction Strength: Ask the patient to spread their fingers apart against resistance. Weakness can suggest ulnar nerve impairment.
• Wrist Flexion and Extension Strength: Test the strength of wrist flexion and extension against resistance, noting any weakness or pain.

7. Sensory Examination

A thorough sensory examination helps identify any nerve impairments or neuropathies:

• Median Nerve: Test sensation over the palmar aspect of the thumb, index finger, middle finger, and the radial half of the ring finger.
• Ulnar Nerve: Assess sensation over the little finger and the ulnar half of the ring finger.
• Radial Nerve: Check sensation over the dorsum of the hand, particularly the area over the first web space.

Use a light touch, pinprick, or tuning fork to assess sensory function. Compare sensations on both hands to identify any differences.

8. Special Tests

Several special tests can be performed to diagnose specific conditions:

• Phalen’s Test: Ask the patient to hold their wrists in full flexion (pushing the back of the hands together) for 60 seconds. Tingling or numbness in the median nerve distribution suggests carpal tunnel syndrome.
• Tinel’s Sign: Lightly tap over the median nerve at the wrist. A tingling sensation in the distribution of the median nerve indicates carpal tunnel syndrome.
• Finkelstein’s Test: The patient makes a fist with the thumb inside the fingers, and the examiner ulnar deviates the wrist. Pain along the radial side of the wrist suggests de Quervain’s tenosynovitis.
• Allen’s Test: Occlude both the radial and ulnar arteries at the wrist, then release one while observing the color return to the hand. This tests the patency of the arteries.

9. Documentation and Interpretation

Accurate documentation of findings is crucial. Describe your findings in detail, including any asymmetry, deformities, pain, or functional limitations. Interpretation of these findings should guide further diagnostic testing or referrals. Common conditions identified during a hand and wrist examination include:

• Osteoarthritis: Characterized by joint stiffness, pain, and bony enlargements (Heberden's and Bouchard's nodes).
• Rheumatoid Arthritis: Symmetrical joint swelling, ulnar deviation, and deformities like swan neck or boutonniere.
• Carpal Tunnel Syndrome: Numbness, tingling, and weakness in the median nerve distribution, often confirmed with Phalen’s or Tinel’s tests.
• De Quervain’s Tenosynovitis: Pain along the radial wrist exacerbated by thumb movement, confirmed by Finkelstein’s test.

10. Conclusion

A thorough hand and wrist examination is a fundamental skill for medical students and healthcare professionals. Mastery of this technique not only aids in diagnosing various conditions but also enhances patient care. Regular practice and attention to detail will improve both your proficiency and confidence in performing these examinations.