The hand and wrist are multi-element structures consisting of balanced joints that are used in many ways in our daily activities and can perfectly fulfill their functions. This body part, which is less protected than it is used a lot, is a settlement area affected by trauma, occupational diseases, and many chronic pathologies.
Physical Examination of the Hand and Wrist:
Joint Range of Motion Measurements:
Wrist: Flexion 80-90 degrees, extension 60-70 degrees, ulnar deviation 30-40 degrees, radial deviation 15-20 degrees, pronation and supination 80-90 degrees.
Thumb: The carpometacarpal joint allows 40-50 degrees of flexion-extension and 0-40-70 degrees of adduction-abduction. The MCP joint can flex 50-70 degrees and extend 10-30 degrees, while the IF joint can flex 50-90 degrees and extend 20-35 degrees. In opposition, the thumb touches all fingers.
MCP and IF joints: They are considered to be at 0 degrees when they are completely straight. In fingers other than the thumb, the MCP joints allow 90 degrees of flexion, 30 degrees of extension, and 35 degrees of radial and ulnar movement. The PIF joints allow 100-120 degrees of flexion. The DIF joint allows 50-80 degrees of flexion and 5-10 degrees of extension. In abduction, the fingers are separated by approximately 20 degrees of equal distance.
In the healthy hand, when the wrist is flexed, the fingers and thumb are extended. When the wrist is extended, the fingers are flexed. (tenodesis effect)
Grip and Holding Strength Measurements:
There are three types of grip:
Cylindrical grip;
pherical grip
Hook grip
There are three types of grip:
Three-finger or three-point grip
Lateral or key grip
Fingertip grip
Sensory Examination:
C6 innervates the first two fingers, C7 the middle finger, and C8 the last two fingers.
Light touch
Pressure
Proprioseception (joint position sense)
Two-point discrimination test
Pick test
Circulatory Examination:
To assess the blood flow to the hand, the color (pink, red, or cyanotic), reflux in the fingers, radial and ulnar pulses at the wrist are examined. The Allen test is also performed for circulatory examination.
Special Tests:
Tinel test
Phalen test
Finkelstein test
Bunnel-Litter test
Extrinsic muscle tension test
Oblique retinacular ligament test
Hand and Wrist Pain Differential Diagnosis:
Articular;
Rheumatoid arthritis
Osteoarthritis
Other forms of arthritis (Gout, psoriatic arthritis, infection)
Joint neoplasms
Ossous;
Bone lesions (Fractures, neoplasms, infection, osteonecrosis (Lunatum osteonocrosis / Kienböck)
Periarticular;
Subcutaneous
RA nodules, gout tophi, painful subcutaneous calcific nodules in scleroderma, nail bed glomus tumor
Palmar fascia
Dupuytren contracture
Tendon sheath:
Wrist extensor tenosynovitis (de Quervain disease) and extensor carpi radialis tenosynovitis
Wrist volar flexor tenosynovitis (KTS)
Thumb flexor tenosynovitis (Trigger thumb)
Finger flexor tenosynovitis (Trigger finger)
Pigmented villonodular tenosynovitis (Giant cell tumor of tendon sheath)
Acute calcific periarthritis (Wrist, MKF)
Ganglion
Neurological;
Nerve compression syndromes
Median nerve:
Carpal tunnel syndrome (wrist)
Pronator teres syndrome (Pronator teres)
Anterior interosseous nerve syndrome
Ulnar nerve:
Cubital tunnel syndrome (Elbow)
Guyon canal (Wrist)
Posterior interosseous nerve syndrome
Radial nerve paralysis (Spiral groove syndrome)
Inferior plexus brachialis: Thoracic outlet syndrome, Pancoast tumor
Cervical nerve roots: Cervical disc herniation, tumors
Spinal cord lesions: Spinal tumors, syringomyelia
Vascular;
Vasospastic diseases seen with Raynaud phenomenon:
Scleroderma, occupational vibration syndrome, etc.
Vasculitis of small or large vessels
Finger ischemia, ischemic ulcers (SLE, RA and Takayusu arteritis)
Tendinitis;
Degenerative and inflammatory diseases of tendons are called tendonitis, and tenosynovitis – tenovaginitis is the inflammation of tendon sheaths, namely parietal and visceral leaves.
It may develop as a result of chronic microtraumas and sports strains during activities, as well as rheumatoid arthritis, tuberculosis, gout and idiopathic.
Clinical Features:
Pain and local tenderness.
Swelling may or may not be present.
Local increase in temperature and redness.
Numbness may occur.
Crepitation and snapping may be detected.
Joint range of motion may be restricted due to pain.
Presence of palpable nodules.
In long-term joint motion limitation, muscle atrophy may develop.
Treatment:
Information about using the wrist and hand
Rest
Medical treatment
Physical therapy modalities
Exercise
Local steroid injection
Surgical intervention
TENDON RUPTURES
Rupture mostly occurs at the termination point of tendons and may be accompanied by fractures. It frequently occurs following numerous microtraumas.
Treatment:
In the postoperative period, dynamic and static splinting and exercises are given accordingly.
Physical therapy modalities: Hydrotherapy (whirlpool bath), pulsed high-frequency electromagnetic currents, ultrasound
Tenosynovitis in RA (hand involvement in joint rheumatism)
Proliferation occurs in the entire synovial sheath. It also affects the structures adjacent to the tendon. In the extensor face, it includes the extensor tendon as well as the extensor reticulum. In the flexor area, it affects the 2nd-3rd and 4th fingers entirely, and the PIF and carpal region between the 1st and 5th fingers.
Tendon involvement in RA: Snapping tendon, stenosis in their sheaths, rupture
Hand Muscles in RA:
Extrinsic muscles undergo inflammation and vasculitis. Intrinsic muscles are more sensitive. Then, protective spasm is gone and their movement causes additional deformity, limitation and pain.
Wrist Joint in Patients with RA:
Radiocarpal Joint Subluxation: Carpal bones can sublux from the distal radius to the volar or ulnar direction or both directions.
Volar subluxation-dislocation: In the advanced stages of the disease, the tendon of the extensor carpi ulnaris muscle shifts to the volar side of the joint, causing this tendon to lose its extensor role. This condition has been named as “caput ulna syndrome”.
Caput Ulna Syndrome:
Weakness in the hand and wrist
Pain and decrease in rotation at the radioulnar joint
Dorsally displaced styloid process of the ulna with painful crepitation
Dorsal tenosynovitis
Extension tendon rüptüre
MCP Joints in Patients with RA:
Ulnar deviation and palmar subluxation deformity usually develop.
Anatomical factors causing ulnar deviation deformity:
Radial lateral collateral ligaments are longer and thinner than ulnar collateral ligaments.
Ulnar intrinsic muscles are larger and have an advantageous location than radial intrinsic muscles.
MCP heads normally point to the ulnar.
During grasping and grasping activities, flexor tendons apply force to the fingers in the ulnar direction.
During hand activities, gravity helps the hand to move in the ulnar direction.
Synovitis occurring in the wrist of patients with RA restricts the wrist’s movements to the ulnar and causes the wrist to go into radial deviation. This is accompanied by radial deviation of the metacarpals and ulnar deviation of the fingers. This condition is known as ‘zig zag deformity’.
It is thought that the stretching of the joint capsule due to synovitis in the MCP joint causes “protective reflex spasm” in the interosseous and lumbrical muscles. The tension in the intrinsic muscles can lead to a “flexor contracture deformity” known as the “intrinsic plus position” in the MCP joint.
Finger Joints in Patients with RA:
In the early acute stage of RA, synovitis in the PIF joint of patients causes a painful, swollen joint, especially in the morning, and the finger takes on a spindle-shaped appearance. In advanced stages of the disease, “swan neck” and “buttonhole” deformities develop.
Swan Neck Deformity:
In a complete swan neck deformity, the PIF, DIF and MCP joints are affected. Hyperextension develops in the PIF joint and flexion develops in the DIF and MCP joints.
Swan neck deformity can occur secondary to synovitis in any of the MCP, PIF or DIF joints. However, swan-neck deformity may also occur due to muscle-tendon imbalance resulting from carpal collapse.
Buttonhole Deformity:
In this deformity, the lateral bands separate, allowing the joint to pass between them. In the initial phase of the deformity, there is flexion in the PIF joint and hyperextension in the DIF joint. However, in the chronic phase, the contracture in the PIF joints is accompanied by hyperextension of the MCP joint.
Thumb Deformities in Patients with RA:
Abduction and adduction in advanced stages in the CMF due to MCF synovitis
IF flexion due to subluxation in the CMF
Shortening and instability in the CMF and IF
HAND REHABILITATION IN PATIENTS WITH RA
Evaluation of the hand with RA
Joint Protection Methods
Splint Treatment: Immobilization splints, elastic traction splints, functional splints
Physical therapy modalities
Exercise
Osteoarthritis (hand calcification)
Hand osteoarthritis is the most common form of generalized osteoarthritis.
It is more common in women over the age of 45 than in men.
There is genetic transmission.
The most commonly affected hand joints are the DIF, PIF and 1st MCF joints.
The most characteristic finding of DIF joint involvement and generalized osteoarthritis is Heberden nodes. It can also be seen in the PIP joint and is called Bouchard’s nodule
Degenerative Changes:
In primary arthritis; there is only spread to the DIP. There may be swelling, insufficiency and pain. Heberden’s nodules develop. This type of arthritis can also occur in young people. There is a familial predisposition.
Generalized OA; most joints in the body are affected. The dominant one in the hand is DIP. In addition, the 1st finger MCP joint is frequently affected.
Erosive OA; there is a progressive destruction in the DIP and PIP.
Risk Factors:
Trauma
Shipyard workers
In obese patients
In patients undergoing hemodialysis due to chronic renal failure
Hypermobility
Hemiparetic hand
Clinical:
Heberden nodules start insidiously, painlessly and manifest over months and years.
They may show a rapid course starting with excessive swelling, redness and pain during movement.
Numbness and decreased dexterity may occur.
Osteoarthritis is quite common in the CMC joint. Radiological examination shows subluxation, narrowing of the joint space and osteophyte formation in the 1st metacarpal base.
Degenerative changes are common in the trapezoscaphoid bone in the wrist. Clinically, pain in the wrist and thumb base, radial and medial swelling and swelling and tenderness in the scaphoid bone are seen.
Diagnosis:
Pain, tingling and stiffness in the hand joints on most days of the last month
Hard tissue enlargement in 2 or more of 10 selected hand joints
Swelling in two or more MCP joints
Hard tissue enlargement in more than two DIP joints
Deformity in 1 or more of 10 selected hand joints
General Approach to Hand Rehabilitation:
Education and prevention
Rest
Medical treatment
Physical therapy modalities:
Superficial heat; paraffin bath, hot water immersion, hydrotherapy, infrared, fluid therapy
Deep heat; pulsed short wave diathermy, ultrasound in water
Cold compression
Electrotherapy; iontophoresis and low-frequency currents (especially TENS), acupuncture, pulsed electromagnetic field
Splinting
Intra-articular injection of LA and corticosteroid
Exercise: Continuous passive motion, stretching and flexibility, ROM and strengthening exercises
Occupational therapy
Surgical approach