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Figure 11.
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Wrist Range of Motion Measurements
Using the Dorsal/Volar Method
A
B
A, Flexion. B, Extension, the stationary arm is aligned
with the midline of the forearm and the moving arm
is aligned with the third metacarpal.
and pronation.
39,40
Aligning the moving arm of the goniometer
on the volar or dorsal aspect of the distal forearm during supination or pronation, respectively, and the stationary arm perpendicular to the oor is a common method, with good intra- and
39
inter-rater reliability.
Another method includes having the
patient hold a pencil and aligning the axis of the goniometer
with the head of the third metacarpal rather than placing it on
39,40
the forearm. Reliability of this method is also good,
thought to be a better measure of functional forearm rotation.
and it is
40
However, it allows substitution with movement of the fourth
and fth rays.
39
Goniometric thumb measures include exion/extension
of the MP and IP joints. Specic measures of the rst CMC
joint include radial (Figure 12A) and palmar (Figure 12B)
abduction. ese CMC joint measures allow the therapist to
assess the patient’s ability to expand the rst web space span,
and assessing palmar abduction provides information on the
APB muscle function that can become weak in people who have
CTS. Opposition of the CMC joint is assessed by documenting
the landmark to which the patient can oppose (eg, patient opposes to the tip of the ring nger; patient opposes to the distal
palmar crease). e Kapandji scale can also be used as an objective measure of thumb CMC joint opposition AROM (Table
12
When PROM is limited in the wrist or ngers, assess joint
6).
play movement such as joint distraction and anterior/posterior
gliding, especially after a period of immobilization.
Strength Assessment
Determine hand strength using appropriate calibrated dynamometers designed for assessing grip and pinch strength. For
grip strength assessment, position the patient in sitting with the
shoulder adducted and in neutral rotation, the elbow exed at
90°, the forearm in neutral rotation, and the wrist in ~30° of extension and slight ulnar deviation. e hand-grip dynamometer has 5 handle positions. When measuring hand-grip strength
using all 5 positions, a graph of the measurement values forms
a bell-shaped curve if the patient consistently exerts maximal ef-
32
fort and has not sustained a median or ulnar nerve injury.
Grip
strength is greatest at the middle handle spacing and weakest at
each end (rst and fth positions) due to extrinsic and intrinsic
32
muscle action at various hand positions.
Submaximal eort
or a nerve lesion may result in a attened curve. Pinch strength
can be measured using key pinch, tip pinch, and 3-point pinch.
Compare the patient’s measurements with established age-related norms for grip
41
and pinch strength
42,43
as well as with
the opposite side. ese measurements are more reliable when
42,43
taking the average of 3 trials.
Strength can also be assessed through individual manual muscle testing, which may help identifying injuries such as
nerve lesions, tendon lacerations, generalized weakness, or tendinopathies. To test the FCU and FCR muscles, position the
patient with the forearm supported in supination. For the FCU
muscle, the patient exes and ulnarly deviates the wrist and resistance is applied to the palm of the hand toward extension
and radial deviation. For the FCR muscle, the patient exes and
radially deviates the wrist and resistance is applied to the palm
of the hand toward extension and ulnar deviation. To test the
ECRB and ECRL muscles, position the patient with the forearm pronated and elbow extended. e patient extends and radially deviates the wrist. Resistance is applied to the dorsum of
the hand into exion and ulnar deviation. To isolate the ECRB
muscle, perform the same test but ex the elbow to reduce the
action of the ECRL muscle. Test the ECU muscle by positioning the patient with the forearm pronated. e patient extends
and ulnarly deviates the wrist. Apply resistance to the dorsum of
the hand into exion and radial deviation.
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For personal use only. No other uses without permission.
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25
Figure 12.
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First Carpometacarpal Joint Range of Motion
A B
A, Goniometric measurement for radial abduction. e axis is at the rst carpometacarpal joint; the stationary arm is aligned
with the second metacarpal; the moving arm is aligned with the rst metacarpal; ask the patient to abduct the thumb away
from the palm, toward the radius; document the start and the end positions (ie, start position 20°; end position 65°; radial
abduction active range of motion, 20°/65°). B, Goniometric measurement for palmar abduction. e axis is at the rst carpometacarpal joint; the stationary arm is aligned with the second metacarpal; the moving arm is aligned with the rst metacarpal;
ask the patient to abduct the thumb away from the palm; document the start and the end positions (ie, start position 20°; end
position 65°; palmar abduction active range of motion, 20°/65°).
Table 6.
Kapandji Scale for Measuring umb Opposition
e patient is able to oppose to the: Kapandji score
Radial (lateral) border of the middle phalanx of the index nger 1
Radial (lateral) border of the distal phalanx of the index nger 2
Volar surface of the distal phalanx of the index nger 3
Volar surface of the distal phalanx of the long nger 4
Volar surface of the distal phalanx of the ring nger 5
Volar surface of the distal phalanx of the small nger 6
Distal interphalangeal joint crease of the small nger 7
Proximal interphalangeal joint crease of the small nger 8
Metacarpophalangeal joint crease of the small nger 9
Distal palmar crease 10
Academy of Orthopaedic Physical erapy, APTA.
26
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For personal use only. No other uses without permission.
Assess the strength in the ngers and thumb by testing
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the extrinsic exor and extensor muscles and the hand intrinsic
muscles. Test the FDS muscle by holding the ngers adjacent
to the test nger in full extension. Ask the patient to ex the
test nger. If the FDS muscle-tendon unit is intact and working
properly, the PIP joint of the test nger will ex and the DIP
joint will remain in extension.
32
e strength of the FDS muscle
can then be tested by applying resistance into PIP joint extension. View test results of the small nger with caution because
some individuals lack, or have a nonfunctional, FDS tendon
to the small nger. If this appears to be the case, release the
fourth nger and test the ring and small ngers simultaneous-
32
ly.
To test the FDP muscle, stabilize the PIP and MP joints
of the test nger in full extension and ask the patient to ex
the DIP joint. If the FDP muscle-tendon unit is intact, the tip
of the test nger will ex. To test strength of the FDP muscle, apply resistance into DIP joint extension. To test the FPL
muscle, support the patient’s palm in supination and stabilize
the thumb MP joint. Ask the patient to ex the IP joint of the
thumb and apply resistance to the distal phalanx into extension.
To test the ED muscle, position the patient with the forearm
pronated. e patient relaxes their IP joints and extends the
ngers at the MP joints. Apply resistance to the MP joint into
exion while stabilizing the wrist. To test the EPL muscle, position the patient with the forearm pronated on a table, then lift
their thumb toward the ceiling at the CMC joint. Apply resistance to the thumb distal phalanx toward the table. To test the
EPB muscle, position the patient with the forearm supported
in neutral rotation. e patient radially abducts the CMC joint
and slightly exes the thumb MP joint. Apply resistance at the
thumb’s proximal phalanx into exion. With the patient in the
same position, test the APL muscle. e patient radially abducts
the thumb at the rst CMC joint. Apply resistance at the rst
metacarpal into adduction.
Test intrinsic muscle strength to identify nerve injuries as
well as intrinsic muscle lesions. Resist the APB muscle to test for
median nerve function. Position the patient with both hands
at on the table, palms up. e patient abducts the thumbs
away from the palm, toward the ceiling. Apply resistance to the
proximal phalanx toward the palm into adduction (Figure 13).
Resist the rst dorsal interosseous muscle to test for ulnar nerve
function. e patient sits with the ulnar aspect of their hand on
the table and abducts the index nger away from the long nger
toward the ceiling. Apply resistance at the distal aspect of the index proximal phalanx into adduction (Figure 14). Assess ulnar
nerve function and dorsal interosseous muscles by asking the
patient to abduct their ngers; apply resistance into adduction,
primarily at the small nger. is however is also the motor test
for C8, so there may be weakness if there is a proximal lesion.
More intrinsic manual muscle testing procedures can be found
in Rehabilitation of the Hand and Upper Extremity.
32
Provocative and Special Tests
e following special tests can help verify specic diagnoses
of the wrist and hand (test the unaected side for comparison).
Wrist
De Quervain tendinopathy: e examiner performs the Fin-
kelstein test by asking the patient to actively ulnar deviate the
wrist over a table edge with the forearm in neutral rotation. e
examiner then passively exes the thumb across the palm.
44
A
positive test reproduces the patient’s pain. Dawson and Mud-
45
gal
suggest performing the Finkelstein test in a 3 step process.
In step 1, the patient actively ulnar deviates the wrist over a
table edge with the forearm in neutral rotation. If the examiner
desires further provocation, a passive overpressure to the wrist
in the direction of ulnar deviation is applied (step 2). If even
further provocation is desired, the examiner passively exes the
thumb while the wrist remains in ulnar deviation (step 3). In
doing a 3-step process, the examiner stops when provocation
produces pain, and considers it a positive test. e examiner
does not need to perform all 3 steps.
e Eicho test is performed by asking the patient to
clench a exed thumb in their st. e examiner then passively
Figure 13.
Manual Muscle Test for Abductor
Pollicis Brevis
Have the patient place their hand on the examination
table with the palm up; ask to abduct their thumb
away from the palm toward the ceiling; apply resistance to the distal aspect of the thumb proximal phalanx toward thumb adduction.
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For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
27
Figure 14.
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Manual Muscle Testing for the First
Dorsal Interosseous Muscle
Have the patient seated and place the ulnar aspect of
the hand on the table; ask the patient to move their
index nger toward the ceiling; apply resistance to the
distal aspect of the index proximal phalanx pushing
toward the long nger.
ulnar deviates the wrist.44 According to Wu et al,44 the Finkelstein test produces fewer false positives than the Eicho test (0
with Finkelstein test versus 8 with Eicho test; specicity 100%
for Finkelstein test and 89% for Eicho test). Interestingly, the
Eicho test has been labeled as the Finkelstein test in many
textbooks.45
Intersection syndrome: It is important to dierentiate De
Quervain tendinopathy from intersection syndrome by noting
the location of the patient’s symptoms. Intersection syndrome
is an inammatory condition occurring at the crossing point
between the muscles of the rst dorsal compartment and radial
wrist extensor muscles.
46
A patient with intersection syndrome
complains of pain approximately 2 cm to 4 cm proximal to the
wrist, where the tendons of the rst extensor compartment (APL
and EPB) cross over the tendons of the second dorsal compartment (ECRB and ECRL), and the location is also often more
dorsal in the forearm than what is seen with De Quervain tendinopathy. Individuals with intersection syndrome may complain of a friction or squeaking sensation in the distal forearm
when moving the wrist and thumb.
syndrome can be done by resisting wrist extension.
47
Testing for intersection
48
A positive
test will reproduce the patient’s symptoms, but also note the
location of the symptoms.
Scaphotrapeziotrapezoid (STT) joint arthritis: To evaluate
for the presence of STT joint arthritis, the examiner places the
patient’s wrist and forearm in neutral position. en, the therapist applies a pressure to the scaphoid tubercle while radially
and ulnar deviating the wrist.
48
e result is positive when the
maneuver causes pain. is maneuver may also be painful with
a SL joint instability or radiocarpal joint arthritis.
48
ere are no
diagnostic accuracy data available on this test. It is important
when examining the radial side of the wrist to be able to dierentiate between pain at the rst CMC joint, the rst dorsal extensor tendon compartment (De Quervain tendinopathy), and
the STT joint. Palpation of this region may be useful to better
localize the origin of the symptoms.
Dorsal wrist syndrome (occult ganglion): e nger exten-
sion test is used to determine the presence of dorsal wrist syn-
drome or an occult ganglion. e examiner places the patient’s
wrist and MP joints in exion and resists long nger extension
at the MP joints. Pain in the third and fourth dorsal compartments at the wrist may indicate an occult dorsal wrist ganglion
(sensitivity 100%; positive predictive value 92%). is test may
also be indicative of SL joint pathology.
49
Wrist instabilities: Wrist instability can occur through dis-
ruption of the SL, lunotriquetral, or intercarpal ligaments. e
scaphoid shift test is used to test for SL joint instability or
dissociation. e examiner palpates the scaphoid tubercle on
the volar aspect of the wrist and rst passively ulnar deviates
and slightly extends the patient’s wrist. en, while applying
dorsal pressure on the scaphoid tubercle, the examiner passively
moves the wrist into radial deviation and slight exion (Figure
15). With instability or dissociation, the dorsal pressure causes
the scaphoid to sublux over the dorsal rim of the radius. Relief
of the pressure causes the scaphoid to reduce with an audible or
palpable clunk.
50
e test result is positive if it both produces a
clunk and the maneuver recreates the patient’s symptoms. Kitay
and Wolfe
50
indicated the result might be falsely positive in onethird of individuals due to ligament laxity, but the examiner
should suspect a SL ligament injury when there is a positive
scaphoid shift test along with a history of wrist trauma such
as a FOOSH. Diagnostic accuracy data have been reported by
LaStayo and Howell
51
(sensitivity 69%, specicity 66%, posi-
tive predictive value 48%, negative predictive value 78%) and
52
Valdes
(mean positive likelihood ratio [PLR] of 2.76, mean
negative likelihood ratio [NLR] of 0.25).
Another test for SL joint instability is the SL ballottement
test. With the patient’s forearm pronated, the examiner stabilizes the lunate with the thumb and index nger of one hand,
and with the other hand, grasps the scaphoid (volarly at the
scaphoid tubercle and dorsally at the proximal pole). e examiner then moves the scaphoid on the lunate dorsally and volarly.
e result is positive if the maneuver recreates the patient’s pain
and there is laxity or crepitus.
53
Findings should be compared to
the uninvolved side as laxity may exist bilaterally.
To perform the lunotriquetral (LT) ballottement test,
with the patient’s forearm pronated, the examiner palpates the
28
Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
Figure 15.
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Scaphoid Shift Test
A B
A, Palpate the scaphoid tubercle with your thumb and passively
place the wrist in ulnar deviation and slight extension. B, While
maintaining rm pressure on the scaphoid tubercle, passively move
the wrist into radial deviation and slight extension. e result is
positive if a clunk occurs (as the scaphoid subluxes over the dorsal
rim of the radius) and the patient’s pain is recreated; the release
of the examiner’s pressure may also cause a click as the scaphoid
reduces back into the radial fossa.
Reprinted with permission from Wadsworth C, Barch E, Erickson M. e Wrist
and Hand: Physical erapy Patient Management Utilizing Current Evidence:
Home Study Course 21.2.4. La Crosse, WI: Orthopaedic Section, APTA Inc;
2011.
lunate with one hand and the pisotriquetral complex with the
other; the examiner moves the pisotriquetral complex dorsally
and volarly while stabilizing the lunate.
54
e result is positive
if the maneuver recreates the patient’s pain and there is substantial laxity, clicking, or crepitus. Studies however show this test
may have limited clinical utility. LaStayo and Howell
51
reported the following values for the LT ballottement test: sensitivity
64%; speci city 44%; positive predictive value 24%; negative
predictive value 81%. Prosser et al
55
reported a PLR of 1.03
(95% con dence interval [CI]: 0.16, 6.52) and a NLR of 0.80
(95% CI: 0.35, 1.80) when using arthroscopy as the reference
standard.
To identify midcarpal instability (disruption of the ulnar
intercarpal ligaments, ie, dorsal radiotriquetral and palmar ulnar arcuate ligaments
56
), the examiner places the patient’s wrist
in neutral and the forearm in pronation. e examiner stabilizes the distal forearm and applies a volar directed force at the
capitate while simultaneously applying an axially directed load
to the wrist. e examiner then ulnar deviates the wrist. e
test is positive if a painful clunk occurs that also reproduces the
patient’s pain toward the end of ulnar deviation.
57
Prosser et al
55
reported a PLR of 2.67 (95% CI: 0.83, 8.60) for the midcarpal
instability test when using arthroscopy as the reference standard. ese authors concluded this test is very imprecise.
Ulnar-sided wrist pain: Several pathologies can con-
tribute to ulnar-sided wrist pain. ese include injuries
to the lunotriquetral (test described above), ulnocarpal, or DRUJ ligaments; the TFCC; or the ECU tendon. Arthritic or degenerative changes at the DRUJ or
pisotriquetral joint can also contribute to ulnar sided
wrist pain. Tay et al
58
indicated the ulnar fovea sign can
be used to detect disruptions of the DRUJ ligaments
from the fovea of the ulnar head or ulnotriquetral ligament injury (sensitivity 95%; speci city 87%; positive
predictive value 89%; negative predictive value 94%).
Schmauss et al59 found the diagnostic values of the ulnar
fovea sign to be comparable with magnetic resonance
imaging (MRI) in individuals with TFCC lesions (fovea
sign: sensitivity 95%, speci city 87%, positive predictive value 89%, negative predictive value 94%; MRI:
sensitivity 95%, speci city 87%, positive predictive value 89%, negative predictive value 94%). To perform the
ulnar fovea sign, with the patient’s wrist and forearm in
neutral rotation, the examiner palpates in the soft spot
between the ulnar styloid, FCU tendon, volar surface
of the ulnar head, and the pisiform; a positive test will
reproduce the patient’s pain.
A test for the TFCC is the TFCC load (compres-
sion) test, with many variations described in the literature. To perform the test, the patient pronates the
forearm and makes a st. e examiner ulnar deviates
the patient’s wrist and applies an axial load through the
wrist and ulna; the examiner may apply additional load
through the TFCC by moving the carpals on the ulna
60
volarly and dorsally or by rotating the forearm.
positive if it reproduces the patient’s pain. Prosser et al
e result is
55
reported a PLR of 5.56 (95% CI: 1.92, 16.10) and a NLR of 0.15
(95% CI: 0.06, 0.37) when compared with MRI.
To test the integrity of the ulnocarpal ligaments, the examiner suspends the patient’s forearm in pronation, away from
the examination table, and then observes the position of the
carpals in relation to the ulnar styloid. e test is positive when
the examiner observes the ulnar aspect of the carpals sag volarly
61
accompanied by a prominent ulnar head.
e examiner may
attempt to relocate the carpals by placing a dorsal pressure on
the pisiform while stabilizing the ulna. Another test for ulnocarpal ligament integrity is the pisiform boost test (or ulnome-
niscaltriquetral dorsal glide). With the patient’s forearm in a
vertical position (elbow resting on table) and neutral rotation,
the examiner pushes the pisiform dorsally while translating
the ulnar head volarly. e result is positive if the test reproduces the patient’s symptoms or there is excessive laxity of the
51,62
ulnomeniscotriquetral region
(sensitivity 66%, speci city
64%, positive predictive value 58%, negative predictive value
51
69%).
e piano key sign can be used to examine the DRUJ for
instability. With the patient’s forearm in neutral rotation, the
examiner stabilizes the radius and presses the ulnar styloid in a
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29
volar direction; in a positive sign, when pressure is released, the
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60
ulna will spring back up to its original position.
Another test
for integrity of the DRUJ ligaments is the piano key test, or
DRUJ ballottement test. While stabilizing the radius, the examiner applies a volar and dorsal overpressure to the ulna while
60
holding the forearm in pronation, supination,
63
position.
e result is positive if the patient complains of pain
and in a neutral
or if the DRUJ exhibits excessive laxity. In a stable wrist, laxity
62
decreases toward the end positions.
According to a case series,
another test for DRUJ instability is done by simultaneously palpating both DRUJs during pronation and supination to assess
and compare the amount of glide that occurs. With the patient
resting the forearms in pronation, the examiner palpates the
dorsal DRUJ with the index nger and places the long ngers
on the ulnar head. e examiner rotates the patient’s forearms
through pronation and supination and compares movement
between the radius and ulna between the 2 sides (sensitivity of
90-100%).
64
To test the ECU for subluxation, the examiner palpates the
ECU tendon with the patient’s wrist in slight ulnar deviation
and pronation, and while maintaining palpation, the patient
slowly rotates the forearm. e test is positive if the ECU tendon snaps out of the ulnar groove during forearm rotation. A
positive test may also cause pain.
e ulnar compression test can be done to detect DRUJ
inammation or arthritis. e examiner compresses the ulnar
60,65
head into the sigmoid notch of the radius.
is compression
may also be combined with forearm pronation and supination.
e result is positive if it recreates the patient’s pain. Pisotriquetral degenerative arthritis can be detected using the pisotrique-
tral grind test. e examiner palpates the pisiform and applies
a dorsal pressure while applying a volar counter pressure to the
triquetrum. is maneuver can also be performed while the
66
patient exes and extends the wrist.
e test is positive if it
reproduces the patient’s pain.
Hand
First CMC joint osteoarthritis: To perform the pressure
shear test, the examiner holds the base of the metacarpal with
the examining hand and stabilizes the wrist with the opposite
hand with the wrist and metacarpals in a neutral position. With
the examining hand over the anterior oblique ligament, the examiner applies a shear force between the metacarpal base and
67
the trapezium.
To perform the CMC grind test, the examiner
compresses the rst metacarpal into the trapezium using an axial load and rotates the metacarpal. In both tests, provocation of
67
the patient’s pain is considered a positive test. Sela et al
compared diagnostic accuracy, sensitivity, and specicity of these
2 tests using radiographic ndings as the reference standard.
Results indicated the diagnostic accuracy of the shear and grind
tests were 98% (95% CI: 94, 100) and 70% (95% CI: 61, 78),
respectively. Sensitivity was higher for the shear test (99%; 95%
CI: 95, 100) than the grind test (64%; 95% CI: 54, 73), while
specicity was high for both the shear (95%; 95% CI: 77, 100)
and grind (100%; 95% CI: 78, 100) tests. us, there is better
balance between sensitivity and specicity for the shear test, but
because of the high specicity, the grind test is well-suited to
conrm the presence of the condition.
Ligament integrity: To assess ligament integrity at the MP
joint of the thumb, the UCL stress test should be done. e
examiner applies a valgus stress to the MP joint of the thumb
at 0° and 30° exion; laxity of more than 35° with valgus stress
or more than 15° greater than the contralateral side is positive
68
for rupture of the UCL (Figure 16A).
e test is performed
at both angles due to the need to test dierent portions of the
ligament. A test is positive if there is laxity at 1 or both angles.
Digital collateral ligament stress tests should be done to
assess the integrity of the PIP joint collateral ligaments. To examine the stability of the ulnar side of the PIP joint, the examiner applies a valgus (medially directed) force to the joint. To
examine the radial collateral ligament, the examiner applies a
varus (laterally directed) force to the joint. ese tests can be
performed with the joint held at 0° and 30° exion. e result
is positive if there is pain (mild sprain or injury with ligament
intact) or pain and laxity (moderate to severe injury with ligament disruption).
Intrinsic tightness: e Bunnell-Littler test is used to ex-
amine the length of the hand intrinsic muscles. e examiner
holds the patient’s wrist in extension and the MP joint of the
test nger in hyperextension and measures passive PIP joint
exion. en, the examiner exes the MP joint and reassesses
PIP joint exion. e result is positive for intrinsic tightness if
PIP joint motion increases with the MP joint in exion.
Vascular integrity: e Allen test should be used to test
for vascular disorder or arterial occlusion. e examiner asks
the patient to open and close their st several times and then
make a tight st. e examiner simultaneously compresses
both the radial and ulnar arteries at the wrist. e examiner
asks the patient to open the hand, which should be “white and
32(p59)
blanched”
following the pumping maneuver. e examiner
releases one of the arteries and observes blood ow back into
the hand and then repeats the entire process for the other artery.
A result is positive when the hand does not revascularize, or is
sluggish to revascularize, upon removal of the arterial pressure.
One can also perform this test on a single nger, occluding and
releasing digital arteries.
Dexterity and Functional Testing
ere are a variety of commercially available tests and
measures to assess patient dexterity and ne motor use of the
hand. Reliability and validity are adequate and normative data
are available on the tools listed here. A therapist does not always perform this aspect of the evaluation, but if a patient’s
daily activities, work, or recreational participation include ne
motor hand use, then the therapist should more thoroughly assess hand function and dexterity. Examples of the clinical tools
30
Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
Figure 16.
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Grade III Ulnar Collateral Ligament
(UCL) Sprain
A
B
A, Ligamentous testing of the ulnar collateral ligament with the individual under anesthesia. B, An
intraoperative picture of a Stener lesion prior to the
repair of the ulnar collateral ligament. e instrument has been placed under the adductor expansion
with the ruptured ulnar collateral ligament observed
retracted to a resting position proximal and dorsal to
the aponeurosis.
available include (but are not limited to) the Functional Dex-
69,70
terity Test,
Nine-Hole Peg Test,
and the Jebsen-Taylor Hand Function Test.
Neurological Testing
70,71
Purdue Pegboard,
70
70,72,73
Visually assess the patient for nerve-specic atrophy, postural deformity, and vasomotor, sudomotor, and trophic changes as described in other sections of this monograph. Further
neurological testing includes an upper quarter screening that
assesses dermatomes, myotomes, and deep tendon reexes for
the nerve roots supplying the upper extremity. In addition, peripheral nerve assessment through systematic testing of sensation and muscle strength for key cutaneous areas and muscles
innervated by the median, ulnar, and radial nerves should be
performed. Testing should be done in a proximal to distal fashion to identify the site of the lesion.
When the therapist suspects a nerve lesion, more specic
sensory testing can be done, including sensory threshold testing using monolaments, two-point discrimination (2PD),
provocative tests, tests for sympathetic or autonomic respons-
34
es, touch localization, and functional tests.
Semmes-Wein-
stein monolaments are nylon laments used for measuring
74
touch-pressure threshold.
ey are available as a full set (20
monolaments) or a mini set (5 monolaments). e mini set
includes monolaments of the following values: 2.83 (normal
sensation), 3.61 (diminished light touch), 4.31 (diminished
protective sensation), 4.56 (loss of protective sensation), and
6.65 (untestable). With the patient’s vision occluded, begin
with the smallest monolament and progress to larger monolaments until the patient senses a touch. For the rst 3 monolaments, apply a perpendicular force to the ngertip 3 times lasting 1 to 1.5 seconds each time, with 1 to 1.5 seconds between
74
each trial.
Apply the fourth monolament 1 time, just until
it bends. Apply the fth, or 6.65 monolament, 1 time also,
just to skin blanching. If the patient is unable to sense the 6.65
monolament, the therapist may choose to use a pin prick. If
the patient feels a pin prick, then there may be some potential
nerve function present. Map the areas tested on a hand diagram
and repeat the test over time to assess change. For accuracy, reliability, and validity, the monolaments should be calibrated
74
and undamaged, in their original size and length.
Two-point discrimination is a measure of innervation
density; whereas the monolaments test innervation threshold. Consider the analogy of students in a classroom. Twopoint discrimination measures how many students are present
and monolaments measure how many students are awake. To
test static 2PD, begin with the 5 mm distance (between the
2 points) and randomly apply 1 or 2 point(s) to the skin on
the ngertip(s) in a longitudinal orientation until the point
74
of blanching.
Ask the patient to indicate if they feel 1 or 2
points. If the patient can feel the 5 mm distance, repeat the test
at progressively smaller distances until the patient can no longer
discriminate between 1 and 2 points. If the patient cannot feel
the 5 mm distance, progressively increase the distance until the
patient can accurately discriminate between 1 and 2 points. e
largest distance used in the testing is 15 mm. Normal static 2PD
74
is less than 6 mm.
7 of 10 trials to demonstrate accuracy for the distance tested.
One can also assess moving 2PD. Dellon and Kallman
e patient must give a correct answer on
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75
suggest moving 2PD correlates to patient function and object
recognition. e therapist assesses moving 2PD beginning with
the 8 mm distance and subsequently progressively decreasing
the distance down to 2 mm, which is considered normal for this
test. Place the point(s) side-by-side on the radial or ulnar border
of the distal phalanx near the DIP joint crease, and move the
74
point(s) longitudinally, in a proximal-to-distal direction.
Ask
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31
the patient if they feel 1 or 2 points. Again, the patient must
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give a correct answer on 7 of 10 trials before proceeding to the
74
smaller level.
Both static and moving 2PD have traditionally been
part of a comprehensive neurological examination, however,
74
Bell-Krotoski
indicated that 2PD lacks force control. She
suggested that skin blanching is dependent on skin condition,
and skin condition is too variable among individuals to be a
valid indicator of force control. Also, when examining a pa-
76
tient with nerve compression, Bell-Krotoski et al
indicated
that Semmes-Weinstein monolaments (innervation threshold)
detect nerve compression earlier than 2PD (innervation density). is is because innervation threshold, along with vibratory
sensation, is one of the rst sensory modalities to be aected in
compression neuropathies. A patient with nerve compression
loses 2PD later in the course of the disorder.
77
Below are provocation and tissue dierentiation tests that
can be used clinically to detect nerve lesions.
Figure 17.
A
Froment Sign
• Tinel sign for CTS: Tap over the median nerve at the carpal
tunnel. e test is positive if tapping reproduces paresthesia
in the corresponding nerve distribution.
• Tinel sign for compression at the supercial sensory branch
of the radial nerve: Tap at the radial styloid. e test is positive if tapping reproduces paresthesia in the corresponding
nerve distribution.
• Phalen test for CTS: Extend the patient’s elbow and allow
the wrist to ex and ngers to extend for 60 seconds. e test
is positive if paresthesia develops or increases in the median
nerve distribution.
•
OK sign for AIN lesion: Instruct the patient to make the
OK sign, bringing the tips of the thumb and index nger together. Look for IP joint exion of the thumb and DIP joint
78
exion of the index nger.
e test is positive if the patient
brings the pulps of their thumb and index ngers together
rather than the tips, making a teardrop shape rather than a
circle.
• Froment sign for ulnar nerve lesion: Instruct the patient to
hold an index card or sheet of paper using a key pinch. Try
to pull the card away. e test is positive if the IP joint of the
thumb exes indicating use of the FPL muscle to compensate
for weakness or loss of the AP and FPB (deep head) muscles
(Figure 17).
TRAUMATIC HAND DISORDERS
Tendon Injuries
Surgical repair is necessary to restore function for ruptured
or lacerated tendons. Injuries to the tendons of the wrist exors
and extensors can often be treated with repair and a period of
immobilization followed by progressive loading and exibility activities. But injuries within the hand, where recovery of
signicant tendon glide is required to regain multi-joint motion can challenge both the surgeon and the therapist. Despite
B
A, Ask the patient to pinch a piece of paper or index
card using a key pinch. In the uninvolved hand, the
patient’s interphalangeal joint is held in extension as
the adductor pollicis muscle is used to pinch. B, In a
patient with an ulnar nerve injury, when the adductor
pollicis muscle is weak or absent, the patient substitutes by pinching with the exor pollicis longus, a
muscle innervated by the median nerve.
improved understanding of the biology involved with tendon
healing, innovations in surgical repair, and progressive rehabilitation, a good to excellent consistent outcome can be dicult to
achieve.79 is can be particularly true in exor tendon injuries
within the hand in zone II (Figure 18). Zone II is dened as
the area proximal to the FDP tendon insertion (zone I includes
the FDP insertion) to the level of the metacarpal heads (Figure
6A). Zone II is the location of the 2 extrinsic exor tendons
within the bro-osseous tunnel. Dy et al80 reported residual impairment as high as 7 to 20% following tendon repairs in the
32
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Figure 18.
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Zones of Flexor Tendon Injury
Zone I: ngertip to proximal interphalangeal joint
crease; zone II: proximal interphalangeal joint crease
to the distal palmar crease; zone III: distal palmar
crease to the distal margin of the exor retinaculum;
zone IV: carpal tunnel; zone V: the area proximal to
the wrist crease in the forearm.
hand. Even small limitations of tendon glide can result in a sig-
nicant inability to achieve a composite st. is section of the
monograph will focus on surgery and rehabilitation of tendon
injuries within primarily zones I and II, due to the specicity
and complexity of their management.
Goals of tendon surgery include performing a strong repair
with minimal gapping between the tendon ends at the repair
site; providing adequate venting, which is partial or complete
excision of areas in the pulley system to allow sucient space
through which the repaired tendon can slide; minimizing interference with tendon vascularity; and maintaining a smooth
81
gliding surface at the repair site.
A quick review of the healing
processes within the tendon will assist in the understanding of
the issues surgeons and therapists must attempt to balance in
this patient population. e local tenocytes of a healthy tendon
maintain the integrity of an intact structure, however, following
injury, a signicant number of undierentiated mesenchymal
cells from the surrounding epitenon proliferate and migrate
into the tendon gap. e signicant inux of broblasts allows
for the active formation of scar within the tendon. Some adhesions can also be created between the tendon and the tendon
82
sheath during this period of high cell productivity.
Historically, surgeons immobilized patients post-tendon repair for a
few weeks. Although immobilization allowed tendon healing,
and minimized the chance of tendon rupture, adhesions to surrounding tissues limited recovery of tendon glide and therefore
nger motion. Joint stiness exacerbated the issues created from
the sustained period of immobilization. Surgical innovations
have allowed postoperative protocols to minimize the period
of immobilization and instead, allow early passive and active
83
motion.
Surgeons have focused on developing suture materials
and techniques resulting in a stronger repair, able to tolerate suf-
84,85
cient load for early motion within the rst week.
A repair
of sucient strength allows tendon glide early in the healing
process, in theory, prior to adhesion formation. Researchers are
also focusing on altering the natural healing responses in such
a way as to maximize tendon strength and minimize surrounding adhesions. Examples of some of the current research with
animal tendons in vivo or in vitro include (1) peritendinous
injections of Substance P that may alter the proliferation of broblasts; (2) the use of pharmacological agents at the time of
surgery to inhibit the adhesion formation during the critical
early period of protection; (3) the use of patient-derived stem
cells placed in the tendon gap to promote repair response within
the tendon; and (4) the use of dierent substances (natural and
synthetic) to promote a smooth surface on the repaired struc-
82
ture to minimize friction during tendon glide.
Today, surgeons typically request postoperative rehabilitation involving early but protected motion, knowing that mo-
tion, not load, is the critical factor to optimize tendon glide.
86
Longer periods of immobilization are now reserved for pediatric
patients, patients who cannot comply with early motion programs, and those with concomitant bony or soft tissue injuries
79
requiring additional protection.
Below is a discussion of an
early motion protocol for exor tendon repairs with the emphasis on repairs in zone II.
Flexor tendons
Flexor tendon lacerations of the hands and forearms are
frequently treated with an acute (within 24 hours of injury) or
delayed (within 3 up to 4 weeks, but preferably within no more
87
than a week of injury) primary repair.
ere are a plethora
of postoperative protocols in existence for managing a patient
with a exor tendon repair – with some protocols incorporating
specic recommendations based on advances in surgical techniques. e majority of programs use a combination of early
active and passive motions of the hand and wrist joints with
controlled forces across the repair. Factors that can inuence
the plan of care include type of injury (eg, a simple laceration,
a torn or shredded tendon, insertion site avulsion); location or
zone of injury; concomitant injuries; and patient age, motivation, general health, occupation, and propensity for scar formation.
Surgical factors also inuence the plan of care with the
number of core suture strands across the repair site, the core
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33
suture size, and the addition of peripheral epitendinous sutures
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all inuencing resistance to gap formation at the repair site and
79
the tendon repair’s ultimate strength.
Among those, the number of core suture strands is one of the most important considerations. Patients who underwent a 2-strand exor tendon
repair 20 years ago followed an early passive motion protocol
(eg, Kleinert, Duran). Most hand surgeons have now switched
to a multi-strand repair (4 or more core sutures). Multiple laboratory studies have demonstrated that 4-strand repairs can tolerate forces of 40 N and 6-strand repairs forces of 50 to 60 N,
providing a force tolerance sucient to allow early passive and
88
limited active motions.
A therapist treating a patient following
exor tendon repair needs to know the surgical technique to assist with decision-making in the postoperative course. e early
motion protocols described later in this monograph would have
an increased risk of rupturing or gapping a 2-strand repair and
therefore are not recommended for those patients. Biomechanical research demonstrating the increase in strength of a 4-strand
repair within the tendon (core suture) has improved condence
in the utilization of early active motion programs postoperatively for those patients.
Surgical literature emphasizes the need to create a strong
repair but to also control the amount of suture material on the
outside of the tendon. e suture material can create friction
83,87
between the tendon and the tendon sheath. Tang et al
reviewed the multi-strand suture patterns currently in use across
the major hand surgery centers around the world. A review of
this work may assist in understanding the eorts in improving
suture design - putting adequate suture material within the tendon yet minimizing the amount of material on the outer sur-
®
face. Fiberwire
is a type of suture material now used by many
hand surgeons, the strength of this material allows the use of
strands of thinner circumference, decreasing the bulk from the
85
suture itself within the tendon.
e overall eect of the wellplaced sutures should allow decreased resistance (friction) to
tendon glide. e stronger sutures combined with good surgical
technique should also minimize gap formation between the repair ends.
Gapping greater than 2 mm has been shown to be a
factor in creating greater amount of resistance to tendon glide
and gapping greater than 3 mm demonstrated an even greater
resistance due to an increased propensity for catching on the
89
edge of the pulleys.
A therapist should review the surgical report or contact
the surgical team directly to obtain information on the repair
(including number of core strands through the repair site), the
integrity of the tendon at the time of the repair, as well as any
associated soft tissue repairs (digital nerves and arteries) prior to
working with the patient.
Finally, one surgical technique being advocated by some
87
hand surgeons is the wide-awake repair.
Here the hand is
anesthetized, with hemostasis controlled by epinephrine, but
the patient remains awake. During the procedure, the patient
may be able to perform active exion of the involved digit(s)
and the surgeon observes successful tendon excursion through
87
the pulley system. Tang and Lalonde
note that if they see any
bunching or gapping at the time of surgery, they will correct the
issue prior to closing the skin. ey also note that any observation of diculty with tendon gliding through the pulleys with
active motion can be carefully corrected at the time of surgery.
ey indicate this technique has signicantly improved patient
outcomes in their practice with less rupturing (decreased rate of
7%) and less need for a future tenolysis, which is a secondary
procedure described later in this monograph, with patients being able to recover with only minimally restricted tendon glide.
Results from the wide-awake procedure have been published
since 2013.
90,91
e early active programs following exor tendon repairs
have the potential for improved tendon glide and therefore
greater functional recovery of nger exion. One must recognize early motion protocols require appropriate surgical techniques, interprofessional communication, meticulous exercise
instruction, and patient cooperation. Providers should make
patients aware of the intensive postsurgical requirements when
deciding on a plan of care.
Postoperative protocols for exor tendons: Surgeons may use
an immobilization protocol when the patient is unable to follow
a complex rehabilitation program, but these are used judiciously. Even for the pediatric population, postsurgical care is moving
toward early motion protocols based on the age and maturity of
the patient.
92
e early stage (3 to 4 weeks post-surgery) consists
of application of a cast with the wrist in 20-25° of exion up
to wrist neutral, and the MP joints in 50-60° of exion. For
children, the surgeon may choose to position the IP joints in
mild exion and include the ngers in a mitten cast. is is
particularly the case for preschoolers (age 5 and younger who
cannot follow a specic protocol). In children in the 5 to 10
years of age range, current research indicates improved results
with early motion with a therapist but immobilization when
not in therapy.
93
e initiation of early motion may be delayed
for 2 to 3 weeks, if necessary, due to concerns of patient tolerance and cooperation. Teenagers, when possible, are instructed
in protocols similar to the adult population as outlined below.
94
In the intermediate stage of the immobilization protocol
(begins at 3 to 4 weeks), the patient progresses to a neutral wrist
orthosis and begins passive nger exion followed by active extension of the IP joints with the MP joints exed at 60-70°.
Within 1 to 2 weeks following immobilization, the patient
begins active motion and dierential tendon gliding exercises (Figure 10) while the wrist is extended to 10° to make use
of synergistic wrist motion (tenodesis). e therapist assesses
movement after 3 to 4 days, and if the dierence between passive and active composite exion is > 50°, the patient most likely has considerable adhesion formation and is ready to progress
to the next phase. e late phase of the immobilization protocol
(4-6 weeks) is dependent on tendon glide. e orthosis is discontinued and the patient begins gentle isolated joint (blocking) exercises (Figure 19). e therapist may add greater stress
34
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