Hand/Wrist History and Physical Exam

Introduction

History

The history (general page) can be very helpful in understanding the etiology and significance of a patient's hand or wrist complaint. Beyond the general components common to all histories, the following are especially important:

Chief Concern and History of Present Illness

Many hand conditions result from injury. The mechanism should be fully explored, including time and place, potential contaminants, position of hand, and any other events noticed.

Chronic conditions should be evaluated in part via analysis of repetitive movements.

Specific symptoms include:

pain
numbness
paresthesias
weakness
changes in temperature
clicking or popping
changes in dexterity

Past Medical History

General health should be probed, with especially important topics including:

diabetes
rheumatologic, cardiovascular, pulmonary, hepatitic, renal, dermatologic conditions
coagulopathy

These can not only shed light on cause, but also potential treatment plans.

Past surgical history, along with problems with bleeding or anesthesia, should be probed.

Social History

Occupation, hobbies, and sports can be very relevant to hand/wrist injury, and can help determine treatment decision.

Physical Exam

The patients should ideally be seated facing the examiner. A small table can be helpful.

inspection
palpation
range of motion
motor
sensory
vascular
special tests

Inspection

brusing and swelling across hand, describing specific locations (more swelling on dorsum due to thick fascia of palm)
posture of the hand: thumb adducted, fingers flexed
deformity (assymetry, in flexion/extension)
muscular atrophy (thenar = carpal tunnel syndrome, interosseous = ulnar entrapment)
autonomic changes (sweating)
wounds (size, orientation, proximity to important structures)
scars
discoloration (infection, pigmentation)

Palpation

Masses
temparature changes
areas of tenderness
crepitation
joint effusion

Range of Motion Assessment

Both passive and active ROM should be examined. Each finger joint should be individually examined.

Motor Exam

Both muscle and tendon should be considered. Muscle strength should be reported according to grade

muscle grade

0: no contraction
1: fibrillations
2: contraction no against gravity
3: contraction able to overcome gravity
4: diminished strength
5: full strength

wrist

flexor carpi radialis and ulnaris: flex wrist and palpate for tendonous contraction
extensor carpi radialis and ulnaris: make a fist and bring back hand" - palpate for contraction

digits

flexor digitorum profundus (FDP): isolation of each distal phalanx, from other joints and other fingers
flexor digitorum superficialis (FDS): isolated flexion of PIP, with other fingers in extension
extensor digitorum communis (EDC) and extensor indicis proprius (EIP): full finger extension

thumb

flexor pollicis longus (FPL): distal thumb joint flexion
abductor pollicis longus (APL) and extensor pollicis brevis (EPB): bring thumb out to side and palpate taut tendons
extensor pollicis longus (EPL): place hand flat on table and lift thumb off

hand