Examination

Wrist & Hand

  • If a mechanism or pattern:
    • When did it happen?
    • What happened exactly?  Try to understand the mechanism and forces involved (if present)
    • What symptoms initially?
      • Where were the symptoms initially?
      • Describe pain – sharp / superficial / deep / ache / burning etc
      • What aggravates and what eases?
      • Were they able to continue?
    • What symptoms now?
      • Have the symptoms changed? Better / Worse? Location?
  • If no mechanism
    • How long has it been there?
    • Is there anything that they believe may have contributed to the development of the problem? Recent activity / inactivity
    • What symptoms are present?
    • Are they there all the time?
  • What treatment has been sought so far?
    • Assessment
    • Investigations
      • If imaging, do they have it with them?
      • If not, can we view it?
        • Private providers use online applications
        • If in another public hospital in Victoria, then can use the “Synapse Mix” service to get the images temporarily put on local network diagnostic imaging servers.
  • What management has been undertaken? Has it been effective
    • Splinting
    • Ice
    • Medications
  • History of problems in that area before
    • When?
    • How was it managed?
      • Assessment undertaken?
      • Investigations
      • Medications
    • Any ongoing problems?
  • Any associated symptoms (if a non mechanical cause or if at all suspicious)
    • Recent illness / fevers / sweats
    • Recent overseas / long haul travel / immobilisation (eg for suspected DVT)
    • Loss of appetite / loss of weight, etc
  • If has a wound
    • Tetanus status
  • If potentially needing procedural sedation or surgery (and consider this for anyone you are contemplating an x-ray for)
    • Fasting status (and tell them not to eat and drink until you tell them it is ok to do so
Goals of assessment in the Emergency Department
  • Identify abnormalities in distal neurovascular function
  • Identify fractures / dislocations
  • Identify tendon injury
Distal Neurovascular Function
  • Colour, Movement, Warmth, Sensation
  • Radial pulse
  • Median, Radial, Ulnar nerve function
    • Rock (Median nerve)
    • Paper (Radial nerve)
    • Scissors (Ulnar nerve)
    • OK sign (Anterior Interosseus branch of the Median Nerve)
Active Range of  Motion
  • Elbow Flexion / Extension
  • Forearm Supination / Pronation
  • Wrist Flexion / Extension
    • If has reasonable wrist flex / ext, then do Radial / Ulnar deviation
  • Finger Flexion / Extension at all joints
    • All finger tips should point to scaphoid, with no scissoring of the fingers
  • Thumb Flexion / Extension, Abd/Adduction and Opposition
Palpation
  • Bones / Joints
    • Palpate entire length of Radius and Ulna
    • Carpus
      • Snuff Box
      • Scaphoid Tubercle
    • Metacarpals
    • Phalanges
  • Muscles
    • Flexor / extensor muscles and tendons
Special tests
  • Scaphoid
    • Axial compression of the first metacarpal
  • Tendon Integrity
    • Test flexor / extensor tendons at both PIP and DIP joints
  • Tendon Pathology
    • Finklestein’s test
  • Stability
    • Collateral ligaments of thumb and fingers at MCP and IP joints
  •  Nerve
    • Tinel’s sign
    • Phalen’s sign
Imaging
  • X-ray
    • No evidence based clinical rules like for the knee and the ankle
    • Because of importance of manual dexterity - have a low threshold for imaging the wrist and hand if the patient has any of the following
      • Swelling / deformity
      • Reduced ROM
      • Tenderness
    • Scaphoid
      • Request scaphoid views if any of the following are present
        • Snuff box tenderness
        • Scaphoid tubercle tenderness
        • Pain on axial compression through the first metacarpal
  • Ultrasound
    • Generally not indicated in ED for most wrist / hand problems unless under direction of hands registrar (eg for suspected flexor tendon injury or suspected UCL rupture / Steiner lesion)