Assessment

A careful history and examination is as important for the wrist and hand as anywhere else.

History

  General — Is the patient left or right handed? Occupation, hobbies and ambitions? How do the symptoms interfere with these?

  Pain — What is the site of the pain, what makes it better or worse, how long has it been present, does it fluctuate?

  Function — Is the grip weak? Are there problems with fine motor tasks, such as doing up buttons, or coarse tasks, such as opening a jar? Are there clicks or clunks?

  Sensation — Loss of sensation? Tingling? Which part of the hand?

  Injury — The exact nature of the injury: a cut (sharp, blunt, dirty?), a crush, a fall (how far?), a bite, a punch, an avulsion?

  General health — Diabetes? Smoking? Steroids? Cardiac or respiratory problems which may influence the choice of anaesthetic?

Examination

  In the injured patient, are there Airway, Breathing or Cir­culation problems which should take priority?

  Skin — Are there cuts or bruises? Is there skin loss, and if so are tendons or bone exposed? Are there previous sur­gical or traumatic scars? Are there signs of infection?

  Bones — Is there deformity or tenderness? The precise of tenderness can be diagnostic, for example a tender lunate with Kienbock’s disease or a tender anatomical snuffbox with a scaphoid fracture.

  Joints — Is there deformity or tenderness? Ligament stability should be tested by stabilising the proximal bone and gently stressing the distal. The active and passive range of movement in each joint should be established. A similar restriction in both active and passive movement may be caused by pain or joint stiffness. A discrepancy may be due to tendon rupture, tendon adhesions or a nerve palsy.

  Tendons — Passive tenodesis is a useful screening test: the hand is relaxed and the wrist is moved into flexion and then extension by the examiner. As the wrist extends, the fingers should curl into a neat cascade, and as the wrist is flexed the fingers should open. The function of each individual tendon is established. Flexor digitorum pro fundus is tested in each finger by supporting the proximal interphalangeal joint and middle phalanx then asking the patient to flex the distal interphalangeal joint. Flexor digitorum superficialis is tested with the examiner holding the other three fingers straight and asking the patient to flex the proximal interphalangeal joint of the remaining finger. Extensor digitorum communis is tested by asking the patient to fully extend the metacarpo­phalangeal joints (interphalangeal joint extension is a function of the intrinsic muscles).

  Nerves — The nerves supplying the hand can be quickly checked. If there is a cut in the palm or finger, the digital nerves should be tested by checking sensation on each side of the finger tip. Two-point discrimination is useful in partial nerve lesions or recovering nerves; two prongs of a paper clip are spread and the patient asked to say whether one or two points can be felt. Normal discrimination in the finger tips is about 6 mm. Tinel’s percussion sign — tapping on a nerve and causing ‘tingling’— is present at the site of nerve compression, a neuroma or at the advancing tip of a recovering nerve. In the unconscious patient or young child, the plastic pen test is helpful. If the nerve is normal then the side of a pen brushed gently across the skin will stick because of the intact supply to sweat glands; if the nerve is divided, the pen will brush off smoothly.

Examining the nerves of the hand

Nerve                   Altered sensation                 Weakness, wasting
Anterior               Nil                                           Flexor pollicis longus, flexor
interosseous                                                       digitorum profundus (FDP)
                                                                                 to index
Posterior                Nil                                          Extensors of wrist and
interosseous                                                       metacarpophalangeal joint
Median           Thenar eminence, palmar          Flexor carpi radialis,
                        side of thumb, index,                  pronator teres, long finger
                        middle and radial half of             flexors (except FOP to    ring
                        ring finger                                     and little), abductor pollicis
                                                                               brevis, opponens pollicis
Ulnar        Ulnar side of hand, palmar              Flexorcarpi ulnaris, FOP to
              side of little finger and                        ring and little finger,
              ulnar half of ring finger                       adductor pollicis,
                                                                            interossei, hypothenar
                                                                           eminence, Froment’s sign
Superficial      Anatomical snuffbox                  Nil                                               

radial

  Circulation — A white or blue fingertip suggests circulation problems. If the finger nail is compressed and then releas­ed, the circulation should return in less than 2 seconds. If not, this suggests either systemic hypotension or loss of the local blood supply. With the Allen test, one can tell whether both radial and ulnar arteries are intact. Both are compressed by the examiner’s fingers, the patient squeezes his or her hand to express the blood and then relaxes. The hand will be white. The examiner then releases one artery; if the hand does not ‘pink up’, that artery is occluded or divided. The test is repeated for the other side.

Investigation

  Plain radiographs — The standard views are a posteroanterior and true lateral. Oblique views are helpful particularly for intra-articular fractures and scaphoid fractures. Special views, for example stress views for ulnar collateral ligament injuries of the thumb or a clenched fist view for carpal instability, are sometimes needed.

  Magnetic resonance imaging (MRI) — This can detect, for example, Kienböck’s disease before it is apparent on plain radiographs and gives some indication of the vascularity of a scaphoid fracture.

  Isotope bone scanning — In difficult cases this helps by disclosing the inflammation that accompanies undisclosed fractures or bone lesions such as osteoid osteoma.

  Wrist arthroscopy — This can diagnose tears of the trian­gular fibrocartilage complex (TFCC), carpal instability and arthritis. Some TFCC tears are treatable arthroscopically.

   Electrophysiology — For a clinically obvious carpal tunnel syndrome these may not be required; for less clear neurological symptoms these tests detect if and where there is nerve compression.