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Hand and Wrist: Physical Exam

- Neurological:
    - two point discrimination:
           - used to test sensory innervation of the digits in adult patients, where as, the ability of skin to wrinkle (when placed in water) is used to test sensation in children;
           - normal values:
                   - thumb: 2.5-5 mm; index: 3-5 mm; other digits: 4-6  mm and base of the palmar aspect of the digits: 5-6  mm
                   - thenar and hypothenar eminences: 5-9  mm,  dorsal aspect of the digits: 6-9  mm, mid-palm region: 11  mm, dorsal aspect of the hand: 7-12 mm
           - reference:
                   - A study of the relative responsiveness of five sensibility tests for assessment of recovery after median nerve injury and repair.
                   - The two-point discrimination test - time for a re-appraisal?
    - tinel's sign:
           - may be positive w/ nerve compression;
           - may be used to following healing of nerve repair;
    - brachial plexus - exam:
           - median (AIN, high median lesions, low median lesions);
           - radial (PIN):
           - ulnar (high ulnar lesions, low ulnar lesions);

- Vascular: (diff dx)
      - see: vascular repair technique:
      - allen test of wrist: radial artery, superficial palmar arch, ulnar artery);
      - allen test of common digital artery
      - allen test of individual fingers

- Joint ROM:
      - functional ROM for wrist flexion and extension is 65 deg;

        finger: mp/f/ext   pip/f/ext   dip/f/ext
                   90        0-110        80

        thumb: IP/flex/ext   mp/f/ext  
                90 to -20     50-0    

        wrist: flex    ext    r/dev.   u/dv.   pronation  supination
                75     70      25       45        60          60  

- Test for Tendon Contractures:
    - extrinsic contractures: note whether the patient can fully flex fingers w/ wrist extended;
    - bunnel littler test:
           - MP held in mild extension, attempt to flex PIP joint;
           - if joint can't flex, either intrinsics are tight or capsule contracture

- Motor and Tendon Exam:
    - tendon injuries of the hand
    - FDP and FDS tendons to each finger are individually tested for strength and excursion;

- Tenderness:
    - ulnar sided wrist pain
    - radial and snuff box tenderness

- Misc:
    - triquetrolunate instability;
    - Exam for SLD

- Compartment     Contents         Pathologic Conditions
     1           APL, EPB            DeQuervain's Disease
     2           ECRL, ECRB          Tennis elbow
     3           EPL                 Rupture at Lister's tubercle
     4           EDC, EIP            Extensor Tenosynovitis
     5           EDM                 Rupture (rheumatoid)
     6           ECU                 Snapping at ulnar styloid