Hand evaluation

HAND EVALUATION

BY AMRIT KAUR

Hand function is an important feature in humans over other primates who lack fine control and precision

Bony Anatomy

Phalanges: 14 Sesamoids: 2 Metacarpals: 5 Carpals

– Proximal row: 4

– Distal row: 4

Radius and Ulna

ANATOMY Muscles /Tendons

– Volar wrist- 6

– Dorsal wrist- 9 • 6 compartments

– Volar hand- 10

– Dorsal hand- dorsal interossei

Nerves - 3– Median

– Ulnar

– Radial

Arteries - 2

Is it bone?

Is it nerve?

Is it the ligaments or joints?

Is it muscle or tendon?

HISTORY

Age Handedness Chief complaint Occupation Previous injury Previous surgery

Sx related to specific activities

What exacerbates What improves Frequency Duration

Which part of hand is injured. Flexor tendon respond much more slowly to

treatment than extensor tendon . Within hand there is surgical no man’s land,

which is a region between the distal palmar crease and mid portion of middle phalanx of the finger.

Damage in this area require surgical repair and usually leads to formation of adhesive bands that restrict gliding.

Red Flags

This section deals with screening the patient for possible serious pathologies that could cause wrist or hand pain. These conditions could warrant a referral, or consultation. 

Infections Heat Swelling Pain Redness Inflammation

Fracture/dislocation:Top five physical findings which are most useful in screening for wrist fracture.Localized tendernessPain on active motion Pain on passive motion Pain on grip Pain on supination Bottom line: Any one of the above findings associated with a history of trauma should be sent for radiographs

OBSERVATION– Wrist “attitude”

• How do the carpals and metacarpals align with the distal radius and ulna?

• Is there symmetry?– Deformities , swelling, Muscle girth or presence of

atrophy. Posture -During the posture examination the physical

therapist should examine from the lateral, posterior, and anterior views looking at the position of the cervical and thoracic spine along with the shoulder, elbow, forearm, wrist, and hand.

Carrying angle Shoulder height

PALMAR SURFACE

Creases Thenar and

Hypothenar Eminence

Arched Framework Hills and Valleys Web Spaces

Cascade sign

Assure all fingers point to scaphoid area when flexed at PIPs

Dorsal Hand and Wrist

Height of metacarpal heads Finger nails

– Pale or white=anemia or circulatory– Spoon shaped=fungal infection– Clubbed=respiratory or congenital heart

Common hand and finger deformities Swan neck deformity Boutonniere deformity Ulnar drift Extensor plus

deformity Claw fingers Trigger finger Ape hand deformity

Bishop’s hand or benediction hand deformity

Drop wrist deformity Myelopathy hand Z deformity of the hand Dupuytrens contracture Mallet finger

Palpation

– Bony and Soft Tissue Palpation• Are they where they should be?• Do they feel like they should feel?

– Circulatory and Neurological Evaluation• Hands should be felt for temperature

– Cold hands indicate decreased circulation

• Take pulse – radial artery• Pinching fingernails can also help detect circulatory

problems (capillary refill)• Hand’s neurological functioning should also be

tested (sensation and motor functioning)

Range of motion The available arc of movement within a joint

which can be classified into: Active range of motion (AROM) Passive range of motion (PROM) Total active range of motion (TAROM), also

known as total active motion (TAM) Total passive range of motion (TPROM), also

known as total passive motion (TPM) Torque range of motion (TROM)

TAROM or TAM-Defined as the total ROM achieved when all three joints—metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) of a digit are actively flexed or extended simultaneously, minus any extension deficit at any of the three joints.

TPROM or TPM-Analogous to TAROM, however this measurement is achieved through passively moving the joint.

TROM-Refers to a joint being moved passively through its full available ROM with a known constant force applied.

Standard position for measuring

For finger and wrist measurements, position the elbow on a table at 90° and wrist in neutral.

For elbow pronation and supination, tuck arm into trunk with the forearm in mid position.

InstrumentsGoniometerRuler/tape measureFluid goniometerMULE (microprocessor upper limb exerciser)—used as an assessment and rehabilitation tool

Muscle testing

Weakness or disappearance of voluntary movement may be due to:Failure of the afferent nerveDestruction of muscle tissueIschemiaTendon ruptureTendon adhesions

MeasurementManual muscle testingGrip strengthPinch grip

To test muscle power accurately the examiner must be familiar with theanatomy of the hand and arm, particularly:Origins and insertions of musclesThe general direction and line of pull of each muscleThe relative positions of muscle and tendonsNerve supply and possible anomaliesPossible trick movements

IndicationsPeripheral nerve lesionsTendon transfersNeuromuscular conditions

ContraindicationsWhere movement or the application of resistance is not recommended (e.g. healing phase of tendon repair)

Method of administrationEnsure the patient is positioned appropriatelyEnsure that the part proximal to the tested part is stabilizedSelect the muscle and joint movement required:Check that the PROM is normal/expectedDemonstrate to the patient what is expected

OBSERVE:Movement at the jointAny contraction of the muscle belly and tendon

Palpate:Muscle contractionRecord muscle power:Ensure that the placement of the hand applying pressure is uniformApply pressure directly opposite the line of pull of the muscle being testedApply pressure gradually

Factors that can affect accuracy includePainSwellingJoint mobility/ROMSensory loss

AdvantagesNo equipment requiredInexpensiveQuick to administer

Functional assessment

In terms of functional impairment the loss of thumb function affect 40 % to 50 % of hand function.

Loss of index finger and middle finger function account for 20% of hand function, loss of ring finger and little finger function affect 10% of hand function.

Loss of hand account for about 90% loss of upper limb function.

Function Hand function tests typically fall into two

categories: Norm-referenced tests-Objective grading

systems are used, mainly time as the critical measure of hand function. Researchers favour them, as they are quick and easy to administer and produce objective data.

Criterion-referenced tests- Descriptive standards are used to measure a patient’s performance. They need an experienced person to interpret the results and to achieve consistency with scoring.

Normally wrist is held in slight extension (10-15 degree) and slight ulnar deviation and is stabilized in this position to provide maximum function for finger and thumb.

Excessive radial deviation can affect grip strength adversely.

Flexion and sensation of ulnar digits are controlled by ulnar nerve and are more related to power grip.

Flexion and sensation of radial digits are controlled by median nerve and more related to precision grip.

The muscle of the thumb often used in both types of grips are supplied by both nerves.

In all cases of grip opening, opening of hand, or release of grip depends on radial nerve.

Power grip

Indicator of hand function is measured by isometric grip.

IndicationsTo establish a baseline for treatmentTo monitor progressTo establish final outcome.

ContraindicationsLess than 12 weeks after tendon repair or transferExcessive painPatients with active inflammatory disease.

ToolsJamar dynamometerVigorimeter

Vigorimeter Measures grip strength using air pressure.

Three different-sized rubber bulbs attached via a tube to a manometer. Possibly more comfortable to use than the Jamar dynamometer and due to the ability to vary the sizes, may be better suited for children.

TypesHook gripCylinder gripFistSpherical

Pinch grip or precision grip

Provides a good indication of thumb function. Three different types:pure (otherwise known as tip pinch)Tripod ( chuck or three fingered pinch)key (otherwise known as lateral pinch)

Tools-pinch gauges

ContraindicationsEarly tendon repairsEarly repairs of collateral ligamentsFirst 8 weeks after trapeziectomyExcessive painInflamed joints

Tip pinch grip-The thumb is pinched against the pulp of the index finger whilst the other fingers are flexed.

Tripod pinch grip-Thumb pulp to index and middle finger pulp with remaining fingers flexed.

Key pinch grip-Thumb pulp to lateral aspect of proximal interphalangeal joint of the index finger, other fingers flexed

Tests for dexterity and function

Moberg Nine-hole peg test Purdue pegboard Minnesota Rate of Manipulation Test The Serial Occupational Dexterity

Assessment (SODA)

Other functional outcome measure Michigan hand outcome questionnaire. Functional status scale for hand Simulated activities of daily living

examination Sollerman Hand Function Test Jebsen Hand Function Test

Oedema

oedema is measured to:Establish baselines for comparisonEvaluate a patient’s response to treatmentMonitor the course of a disease process

Tools

Tape measure-Advantages: quick to use, cheap to purchase and able to provide information regarding specific segments.

Accuracy and reliability can be improved by: Calibration of tape measures Measure over anatomical landmarks

Jeweller’s rings-Used to measure the circumference of joints. A range of different-sized jewellers rings are placed over the joints. Quick and easy to use, however expensive to purchase and only allow small joints to be measured

Volumeter -Based on the Archimedes principle: ‘A body partly or completely immersed in a fluid displaces an amount of fluid equal to the apparent volume of that body.’

Sensory testing

Types of sensory dysfunctionHypoaesthesia: diminished sensationParasthesia: abnormal sensationHyperaesthesia: abnormal sensationAnaesthesia: complete loss of sensation

Purpose of sensory testing-To assist in diagnosisTo determine the extent of sensory lossTo determine the level of axonal regeneration (provocative tests, e.g.Tinel’s percussion test)To evaluate nerve conduction efficiency (threshold tests, electrophysiological tests)To evaluate end organ unity/function

To determine level of somatosensory reorganization (ability to interpret stimuli)

To identify the need for surgical intervention

To identify splinting requirements To determine when to commence sensory

re-education To identify level of hand function

Sensory testing is difficult due to:Subjective nature of the testsTechnical difficulties with the tests, e.g. vibration of the assessor’s hand during testing, variation in the application of force when utilizing the assessment t.ools

Indications for testing sensibilityPeripheral/digital nerve repairNerve compressionNerve replantsFlaps/graftsBrachial plexus injuriesCrush injuries

Precautions for testing sensibilityUnderlying vascular or neuropathic diseaseFatigueNegative attitude/poor motivationHypersensitivity/pain

Scar

Burn scar index (Vancouver) Image panel assessment scale (photos) Self-rating scale for patients Non-invasive measurement of scar and skin

pliability (pneumatonometer and Derma-Durameter)

Numeric scar ratings scale (therapist scored)