Clinical Assessment of Wrist and Hand: Occupational Therapist's Perspective - Punita V. Solanki

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4thAnnualNationalConferenceofSocietyforHandTherapy,India12th&13thDecember,2015Pune,Maharashtra,India

ClinicalAssessmentofWristandHand:

OccupationalTherapist’sPerspective

Mobile:+91‐9820621352(Official)+91‐9167180215(Personal)

Email:[email protected]

PunitaV.SolankiMSc(O.T.),ADCR(Mumbai)

OccupationalTherapist

TableofContents

PunitaV.Solanki

1.AppliedAnatomy&BiomechanicsofWrist&Hand.

2.Patient’sDetailedInjury&OccupationalHistory.

3.ClinicalObservation.

4.TriageandQuickScreening&SensoryAssessment

5.VolumeTest.

6.RangeofMotionTesting.

7.PalpationandManualMuscleTesting.

8.SpecialProvocativeTests.

9.StandardizedFunctionalTestsandOutcomesMeasures.

10.PrevalenceandEconomicImpact.

11.QuizTime.

12.Take‐HomeMessage.

13.AcknowledgementsandReferences.

PunitaV.Solanki

“The hands that help are holier than the lips that pray”

~ Robert Green Ingersoll (American Political Leader)

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AppliedAnatomyofWristandHand

AnatomyofRightHand‐DorsalSurface

19Bones&19JointsintheHand

(5CMC,5MCP,5PIP&4DIP)

3of8CarpalBones+Radius+Radio‐UlnarDisc

(TFCC)(WristComplex)

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AppliedAnatomyofWristandHand

AnatomyofRightHand‐VolarSurface

3ArchesofHand CarpalTunnel

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BiomechanicsofWristandHand

WristComplex(Radio‐carpalJoint):2°ofFreedomofMotion

(FoM)(Sagittal&FrontalPlaneMotions)

CMCjointofThumb:3°ofFoM(Sagittal,Frontal&Transverse)

MCPJointsFingers:2°ofFoM(Sagittal&Frontal)

MCPJointThumb:3°ofFoM(Sagittal,Frontal&Transverse)

PIPJoints:1°ofFoM(SagittalPlane:fromExtensiontoFlexion

withNoHyperextension‐0°to110°)(Thumb:0°to90°)

DIPJoints:1°ofFoM(SagittalPlane:fromExtensiontoFlexion

withslightHyperextension.(0°to90°&0°to5°‐10°)

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Functional(Resting)PostureofWristandHand

Wrist:15°‐30°Extension+10°‐15°UlnarDeviation.

CMCThumb:MidwaybetweenFlex‐Ext&Ab‐Ad

MCPThumb:SlightFlexion

MCPFingers:45°to60°ofFlexion

PIPThumb&Fingers:SlightFlexionofabout10°

DIPFingers:SlightFlexionofabout5°

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FunctionalPositionsofWrist

Mostoftheactivitiesofdailylivingareaccomplishedbetween

thewristpositionsof10°Flexionto35°Extension.Greatestarcof

motionupto63°Extensionisemployedduringrisingfromachair

whilstweightbearingoverthehand.

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PositionofImmobilization(ClosedPackedPosition)ofWristandHand

Wrist:30°‐35°Extension+Neutralor5°‐10°UlnarDeviation.

CMCThumb:FullOpposition

MCPThumb:FullOpposition

MCPFingers:90°ofFlexion

PIPThumb&Fingers:FullExtension(0°)

DIPFingers:FullExtension(0°)

(Inthesepositions,theligamentsofeachjointsaretaut/shortened)

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Assessment

“Assessmentisthefirststeptowards

successfulgoalsetting,treatment

planningandoptimalreturnto

occupationalroles(ADL,Work&Leisure)”

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Patient’sDetailedInjuryHistory

InjuryHistory:

Mechanismofinjury/disease(Onset,Duration&Progress)

Locationofpain,characterofpain,intensityofpain(VASscore)

H/oswelling,abnormalsensitivitye.g.paresthesia,burning,

stiffness,weakness,difficultyinactivitiesofdailyliving,work&

leisure/playactivities

Past/PreviousH/osimilarinjuriesoranyrelated,associated

co‐morbidities(physical,psychological,social,environmental).

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Patient’sDetailedOccupationalHistory

OccupationalHistory:

DemographicHistory

Dominanceofhand

Occupation

AbilitiesandInabilitiesinFunction(ADL,Work&Leisure)

Fulltime/parttime/permanent/temporary/free‐lancejob

Availabilityofsickleaves,workshifts,regionaltransfersto

localityinthevicinityofresidence,parttimereturntowork,etc

Levelofwork,workassistance,travelto&frowork,restbreaks

Presenceofinherentriskfactorsofwork‐relatedMSdisorders

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ClinicalObservation

Observefor:(Bilateral)

Localizedorgeneralizedswelling

Trophicchangese.g.changeincoloroftheskin,appearanceofthe

skin(skincreases,shinyorscalyskin),moistureoftheskin(hyperor

hypohidrosis),skintemperature,hairchanges,appearanceofnails,

localbruisingorwoundsduetoinjuryetc

Bonyprojections(duetodegeneratione.g.Heberden’snodesor

subluxationordislocationormalunione.g.dinnerforkdeformityin

maluniteddistalradius#)

Attitudeofthewristandhandwhilstatrestandduringactivityor

exercisesessionorpresenceofanydeformities.

Prominentcontracturedskinoverthepalme.g.Dupuytren’s

contractureoranyothercontractures

Wastingofmuscles

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ClinicalObservation

LocalizedSwelling&TrophicChanges

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ClinicalObservation

DeformityorAttitudeoftheWrist&Hand

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ClinicalObservation

WastingofMuscles

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ClinicalObservation

Dupuytren’sContracture

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TriageandQuickScreening

ClinicalObservationofBilateralWristandHandAppearance.

QuickCheckonBilateralWristandHandMovements:

Up‐Down&Side‐SideMovementofWrist

ExtensionofHandJoints,TableTopPosition,Claw/Hook

Position,FistPosition,SpreadingandGatheringofFingersand

CountingofFingers.

RootAssessment:AgainstResistance

(BreakTest)

C6:WristExtensors

C8:MiddleFingerDIPFlexors

T1:LittleFingerAbductors

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TriageandQuickScreening

ExclusivePeripheralNerveInnervations(AutonomousZones)

Radialnerve:1stdorsalwebspaceofhand

(Anatomicalsnuffbox)

Mediannerve:Distalphalanx(tip)ofindexfinger(2ndfinger)

Other:Tipofthumb

Ulnarnerve:Distalphalanx(tip)oflittlefinger(5thfinger)

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SensoryAssessment

Superficialsensoryassessmentondermatomedistributionof

wristandhandandrecordingitas:

(0:Absent,1:Impairedwith%Lossor2:Intact)

Deepsensoryassessment:

DeepPressure

Weber’s(Moberg’s)Two‐PointDiscriminationTest

(Normal:<6mm,Fair:6‐10mm,Poor:11‐15mm,Protective:1

pointperceived,Anesthetic:0pointsperceived)

(Functionalneedse.g.windingawatch:6mm,handlingprecision

tools:12mmandgrosstools:>15mm)

Dellon’sMovingTwo‐PointDiscriminationTest:Functional

implications.Normalrecognition:2‐5mm

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SensoryAssessment&VolumeTest

Semmes‐WeinsteinTest:Gridpatternofassessmentofhand

andfinger’slighttouchsensation.Onlyonepoint,istestedin

eachsquare.

Stereognosisortactilegnosis:Dellon’smodificationof

Moberg’sPick‐upTest(Normalsubjectscannametheobject

within3secondsofcontact)

Vibratorysense:DistaltoProximalassessmentoverbony

prominenceswithvibratingtuningfork.

HandVolumeTest:

MeasuretapeorVolumetricassessment.Bilateralassessment

forcomparison

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RangeofMotionTesting

TypesofGoniometerforWristandHandRangeofMotionTesting.NormsofRangeofMotionvaluesbyvariousacademicbodies

e.g.AmericanAcademyofOrthopaedicSurgeons,AmericanMedicalAssociation,AmericanSocietyforSurgeryoftheHand.Standardizedpositionsofthepatients,ofthejointsofwrist

andhand,&thegoniometer,whilstperformingrangeofmotiontesting.MethodsofdocumentationsofRangeofMotion.Bilateral

assessmentsalongwithdocumentingnormsandendfeels.A5‐degreemarginoferrorisacceptableforgoniometric

measurementsofjointsinthehandbyanexperiencedexaminerusingstandardizedprotocols.~(Bear‐Lehman,JandAbreu,BC;1989)

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TypesofFingerGoniometer(FG):

RolyanFinger/ToeGoniometer

RolyanFlexion/HyperextensionFG

Jamar8‐InchGoniometer

BaselineStainlessSteelFG

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DocumentationTemplate

Joints LeftHand RightHand Norms

Thumb

PROM EndFeel

PROM EndFeel

ROM EndFeel

CMCFlexion 0°‐15° Firm*

CMCExtension 0°‐20° Firm*

CMCPalmarAbduction 0°‐45° Firm†

CMCRadialAbduction 0°‐70° Firm*

MCPFlexion 0°‐50° Firm*

MCPHyperextension 0°‐10° Firm†

IPFlexion 0°‐80° Firm*

IPHyperextension 0°‐15° Firm†

*AmericanAcademyofOrthopaedicSurgeons(OppositionisMeasuredwithMeasureTape)

†AmericanSocietyforSurgeryoftheHand;MethodUsed:FingerGoniometry

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PalpationandManualMuscleTesting

Standardizedpositionofthepatients,ofthejointsofwristandhand

&oftheexaminer,whilstperformingmuscletesting.

Accuracyofstrengthgradingdependsupon:

stablepositionofthepatient

thefixationofthepartproximaltothetestedpart

precisionoftestposition

thedirectionandamountorpressure/resistance

Methodsofmanualmuscletestinge.g.BreakVs.Maketest,

Scoring:MRC,Daniels&Worthingham,Kendall&McCreary;Subjective

Vs.Objectivemethodsofevaluation.

Consistencyinmethodsofdocumentationsofmuscletesting.

Bilateralassessmentsforcomparison

PurposeofEvaluation:Diagnosis,treatmentoutcomeorprognostic

valueoftreatmentused.

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ManualMuscleTesting

SomeFactsaboutWristandHandMuscleStrength

“Weakness”isusedasanoveralltermcoveringarangeofstrength

fromzero(0)tofair(3)innon‐weightbearingupperlimbmuscles.

Thestrengthofthefingerflexorsisovertwicethatoftheextensors.

FDSisthestrongestmuscleoftheextrinsicsofhand.

2nd&4thdigitalflexortendonsheathannularpulleysystemplaysan

importantroleinmaintainingaconstantmomentarmforfingerflexors.

Theexcursionoftheflexors>extensors,extrinsics>intrinsics.

Thepositionofthethumb&therelationshipbetweenhand&

forearmarethemostimportantdifferencesbetweenpowergripVs

precisionhandling.

Dominanthandgripandpinchstrengthismorethanthe

non‐dominanthandby10%.

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PalpationandManualMuscleTesting DocumentationTemplate

Joint Muscles MMT*Left

MMT*Right

Dynamometer/Electr.MMT(Kgs)

CMCFlexion FPB&FPL 5 5

CMCExtension EPL&EPB, 3+ 5

CMCPalmarAbduction

APB&APL

5 5

CMCRadialAbduction

APB&APL 4‐ 5

MCPFlexion FPB 5 5

MCPHyperextension

EPB 3+ 5

IPFlexion FPL 5 5

IPHyperextension

EPL 5 5

Opposition OP 5 5

* Oxford’sModifiedResearchCouncil(MRC)MMTGradingSystem

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Grip&PinchTesting GripandPinchStrengthTestingandHandMuscleEndurance

Testing(AspertheRecommendationsofASHT,1981)

Subject:shouldbeinsupportedseatedposture

Shoulder:adducted&neutrallyrotated

Elbow:flexedat90°

Forearm:neutralposition

Wrist:0°to30°extension&between0°to15°ofulnardeviation

Hip&knees:whenseatedshouldbeat90°offlexion

Feet:flatontheground.

Threetrialsaretakenofeachhandwitha2‐3minuterestbetween

trialsandthescoreistheaverageofthethreetrials.

JamarDynamometer(Setatsecondpositionfromallof5positions)

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Grip&PinchTesting

GripandPinchStrengthTestingandHandMuscleEndurance


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Grip,Pinch&HandEnduranceTesting



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GripStrengthAssessmentTools



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PinchStrengthAssessmentTools



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SpecialProvocativeTests

CarpalTunnel

Tinel’sTest(tapmediannerveincarpal

tunnel)

Phalen’sTest(holdwristsflexedtogetherfor1min)

TestsforNeurologicalDysfunction

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SpecialTests TestsforNeurologicalDysfunction

UlnarNerve:

Froment’sSign

Jeanne’sSign

CardTest

Egawa’sSign

MedianNerve:

ClaspingTest(BenedictionAttitude/PointingIndex)

PenTest

KilohNevinSign

ApeorSimianHand

RadialNerve:

WristDrop

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TestsforTendons&Muscles

Finkelstein’sTest


SweaterFingerSign

DeQuervain’sTenosynovitis FDPTendonRupture(RFinger)

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TriangularFibrocartilageInjury

LoadedCircumduction

Scapholunateinstability

Watson’sTest

TestsforLigaments,CapsuleandJointInstability

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TestsforCirculationandSwelling

AllenTest

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FunctionalTests

Jebson‐TaylorHandFunctionTest.

MinnesotaRateofManipulationTest.

PurduePegboardTest.

Crawford’sSmallPartsDexterityTest.

BoxandBlockTest.

Nine‐HolePegTest.

SimulatedActivitiesofDailyLivingExamination.(19subtests

ortasksaretestedandtimed.

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FunctionalOutcomesMeasures

PatientReportedOutcomeMeasures(PROM)

Disabilityofthearm,shoulderandhandquestionnaire(DASH):

aregion‐specific30‐itemquestionnaireisthemostwidelytested

instrumentinpatientswithwristandhandinjuries&established

measurementproperties

QuickDASH:establishedmeasurementproperties

PatientRatedWristHandEvaluationOutcomeQuestionnaire

(PRWHE):goodconstructvalidityandresponsiveness&

establishedmeasurementproperties

MichiganHandOutcomesQuestionnaire(MHQ):sufficiently

responsive&goodvaluetopatientswithhandinjuries

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FunctionalOutcomesMeasures

PatientReportedOutcomeMeasures(PROM)

ModernActivitySubjectiveSurveyof2007(MASS07)

TheBostonCarpalTunnelQuestionnaire(CTQ)scale:most

sensitivetoclinicalchange&establishedmeasurementproperties

UpperExtremityFunctionalIndex(UEFI)&UpperExtremity

FunctionalScale(UEFS)

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FunctionalTests&OutcomesMeasures

PROM ScoreItems Validity(V) Reliability(R)

DASH

30Selfreported

Valid ReliableResponsive

QuickDASH

11Selfreported

Valid ReliableResponsive

PRWHE

15Selfreported

CriterionValidity

Test‐retestReliabilityInternalconsistency

BostonCTQ

11Selfreported

Face,contentconstructV

Test‐retestReliabilityResponseRate:90%

MHQ

65Selfreported

Valid Test‐retestReliability

MASS07

10Selfreported

Valid Reliable

UEFI

20Selfreported

Valid Test‐retestReliabilityInternalconsistency

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PrevalenceandEconomicImpact

Reference:dePutterCE,SellesRW,PolinderS,PannemanMJ,

HoviusSE,vanBeeckEF.EconomicImpactofHandandWrist

Injuries:Health‐careCostsandProductivityCostsinaPopulation

‐BasedStudy.JBoneJointSurgAm.2012May2;94(9):e56.

Doi:10.2106/JBJS.K.00561.

Conclusion:Handandwristinjuriesnotonlyconstitutea

substantialpartofalltreatedinjuriesbutalsorepresenta

considerableeconomicburden,withbothhighhealth‐careand

productivitycosts.Handandwristinjuriesshouldbea

priorityareaforresearchintraumacare,andfurtherresearch

couldhelptoreducethecostoftheseinjuries,bothtothe

health‐caresystemandtosociety.

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TakeHomeMessage

“Thehandsaretheinstrumentsofman'sintelligence.”

~AssociationMontessoriInternationale

Assess,AssessandAssessintheBeginning,DuringandAfter

theTreatment.Itisthefirstmostimportantsteptowards

successfuloutcome.

Diagnosisisoftenbasedonclinicalassessment,Investigations

aretoconfirmthefindings,forobjectivedocumentationfor

progressnotes,forinsurancepurpose,forlegalimplications.

Beobservant,updateyourknowledgeandrefineyourclinical

skillswithperfectpractice.

(“Perfectpracticemakesmanperfect.”)

QuizTime

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Which test is this? This is for dorsal interossei (abductors) of

the middle finger. With the hand kept flat on a table palmer

surface down, the patient is asked to move his middle finger

sideways.

Answer:EgawaTest

QuizTime

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Whichhandfunctiontestisthis?

Answer:MinnesotaRateofManipulationTest

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QuizTime

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SayTrueorFalse:

Maximum degree of wrist extension up to 65° is needed whilst

gettingupfromsittingposturewitharmsinweightbearingposition.

Answer:True

Circumductionispossibleonly inthose jointswiththreedegreesof

freedomofmotion.

Answer:False

Protective sensory recovery is the first sign of sensory system

recovery.

Answer:True

Heberden'snodesarehardorbonyswellingsthatcandevelopinthe

distalinterphalangealjoints(DIP)duetoRheumatoidArthritis.

Answer:False

QuizTime

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SelecttheBestCorrectResponse:

1.Thestrongestmuscleamongstalltheextrinsicmusclesofthehandis

a.FlexorDigitorumProfundusb.FlexorDigitorumSuperficialisc.FlexorPollicisLongusd.ExtensorDigitorumCommunis

Key:b(FlexorDigitorumSuperficialis)

2.IfthepatientisunabletomakeafistdespitenormalPROMofalljointsofthewrist&hand,whenthereislimitationinTAM/TPM&absenceofpain,(ExtensorPlusDeformity)isdueto

a.TendonTightness/Adhesionsb.JointArthritisc.Tendonitisd.Tenosynovitis

Key:a

Acknowledgements

PunitaV.Solanki

Ithankmyteachers,seniorcolleagues,sub‐ordinatesfromvarious departments and occupational therapy students ofmyalmamater(SethG.S.MedicalCollege&KingEdwardVIIMemorialHospital),fortherichexperience,inthefieldoforthopaedicrehabilitation,inmyformingcareeryearsofmylife,inthepastmorethan18years.

ItakethisopportunitytothankDr.ApurvaA.PatelSir,SpecializedHandOrthopaedicSurgeonfromWesternSuburbsofMumbai,India,forthevaluableexperiencethatIhavegainedinthepasttwoyearsfromhisumpteennumberof upperlimbcasereferrals.

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RecommendedReading&References

PunitaV.Solanki

Chapter7:Forearm,WristandHand.InOrthopedicPhysical

Assessment.EdsDavidJ.Magee.5thEdition.2008Elsevier.

NorkinCC,WhiteDJ.MeasurementofJointMotion:AGuide

toGoniometry.2ndEdition.1995.F.A.DavisCompany.

NordinM,FrankelVH.BasicBiomechanicsofthe

MusculoskeletalSystem.3rdEdition.2001.LWW.

KendallFP,McCrearyEK,ProvancePG.MusclesTestingand

Function.WithPostureandPain.4thEdition.1993.William&

Wilkins.

PandeyS,PandeyAK.ClinicalOrthopaedicDiagnosis.2nd

Edition.2000.

Andmanymore………………………………………………………………………!

Health & Medicine

Clinical Assessment of Wrist and Hand: Occupational Therapist's Perspective - Punita V. Solanki