|Date published:||19 Sep 2018|
History of presenting complaint and symptoms: Ian Ruther fell on icy path outside of house two days ago, putting her hand down to break the fall (i.e. FOOSH). There was immediate pain in the left wrist below the thumb. She is complaining of increased pain when trying to move wrist and pick up small objects. Patient does not report any noticeable immediate swelling.
Examination findings: Examination should start with observing the motion of the patient’s hand. This observation is helpful in making diagnosis on the whole limb dysfunction and injury that will help in giving valuable information about the function of the hand elbow complex. The patient’s hand should be observed from front to the back. Any kind of limitation hesitancy, symmetry or avoidance of any weight bearing should be noted. Some of the examinations should escape the notice of the patient since some of them occur gradually. (Bunnell, S., 1951)
The entire upper extremity of the limb should be exposed and evaluated when examination is on-going. Elbow motion, active shoulder motion, pronation, and supination of the forearm should be assed effectively. The color of the forearm should be noted in order to conclude on the state of the blood circulation and even on the conditions of the radial and ulna pulses. The swellings and edemas existing edemas should be noted and even on the abnormal posture or position. Evaluation of the skin tenderness, moisture and sensibility should be done. After hand injury, there is a secondary stiffness and limited range of motion (ROM) of other joints of extremity together with the involved hand. Measurements and recordings on the range of both active and passive motion of the wrist, MCP joint, and IP joints of each digit should be done. Documentation of grip and pinch strength should be noted too. Evaluation on the patient ability to carry out simple functions should be evaluated. A simple sketch of the hand with appropriate notations and measurements should be done on the paper since it is usually helpful. (Campbell, D.A. and Kay, S.P.J., 1996)
Differential diagnoses: The parts of the arm that should be investigated are: skin, the nail-bed and fingertip, the muscles, the nerves of the patient’s forearm sensibility and circulation of blood. (Flatt, A.E., 1979)
Investigations & further tests required: After these preliminary tests, there are specific parts of the hand where further analysis should be carried out. They are listed as shown below:
Skin: The examiner should evaluate whether there is a presence or absence of swelling, wrinkles, moisture, scars, color and other surface irregularities. Normally, the palmer skin is thick, tethered, irregularly surfaced and moist to enable traction and durability. The dorsum skin is thin and mobile to permit the motion of various joints. (Frazier, W.H., Miller, M., Fox, R.S., Brand, D. and Finseth, F., 1978)
The nail-bed and fingertip: When making examination on this part of the forearm, one should ensure that the tuft of the distal phalanx is well-padded by the adipose tissue and covered by highly inverted skin which is tethered to the distal phalanx through a series of fibrosepta. (Hammert, W. C. 2010)
Muscles: The muscles of the fore arm are divided into various sections. Hence, examinations should be done on each part respectively as shown below and make the recordings on them.
The first part is the extrinsic muscle. This part is composed of extrinsic flexor muscles, extrinsic extensor muscles and extrinsic extensor muscles. When analyzing the extrinsic extensor muscles, the flexor pollicis longus (FPL) muscle strength should be tested against the resistance supplied by the examiner. The flexor digitorum profunds (FDP) should be tested by asking the patient to bend the tip of his finger. The examiner should stabilize the PIP point as the distal point is actively flexed. The muscle should be tested against resistance too as each finger is being examined. The flexor digitorum superficialis (FDS) should be tested by asking the patient to bend his finger at the middle joint (Weiland, A. J., & Rohde, R. S. 2009). The examiner should stabilize the other fingers so as to block the profundus function. Then the procedure should be repeated for the rest of the fingers. The flexor carpi ulnaris (FCU), flexor carpi radialis(FCR), and palmaris longus(PL) should be evaluated by asking the patient to flex his wrist as the examiner keeps on palpating on the tendoms of these muscles.The PL will be noted as to be lying between the FCR radially and FCU ulnary on the volar surface of the wrist when maneuvering around the forearm. The extrinsic extensor muscles. It consists of the first dorsal wrist compartment, second dorsal wrist compartment, the third dorsal wrist compartment, fourth dorsal wrist compartment, fifth dorsal wrist compartment and the sixth dorsal wrist compartment. The first dorsal wrist compartment consists of the abductor pollicis longus (APL) and extensor pollicis longus. These parts are evaluated by asking the patient to bring his thumb out to the side. The examiner should be palpating around the taut tendons over the radial side of the wrist that is going to the thumb. The second dorsal wrist compartment consists of the extensor carpi radialis longus (ECRL) tendons and the extensor carpi radialis brevis (ECRB) muscles. These parts are evaluated by asking the patient to make a fist and bring his wrist back strongly. The examiner should also provide resistance and palpation on thetendons over the dorsoradial aspect of the wrist. The third dorsal wrist compartment has the extensor pollicis longus (EPL) passing around the Lister’s tubercle of te radius. This muscle can be tested by placing the hand flat on the table and having the patient lifting the thumb off the surface. The fourth dorsal wrist compartment has the extensor digitorum communis (EDC) and the extensor indicis proprius (EIP) muscle tendons. They are examined by asking the patient to straighten his fingures and by making observations on the MCP joint extension. The EIP can be examined separately by asking the patient to bring his pointing finger out straight with the other fingers bent in a fist. The fifth dorsal wrist compartment has the extensor digit minimi (EDM) (Weinzweig, N., & Weinzweig, J. 2005). This is tested by asking the patient to straighten his small finger with others bent in the fist. This will help in extending the MCP joint of the small finger. The sixth dorsal wrist compartment has the extensor corpi ulnaris (ECU). This is examined by asking the patient to pull his hand up and out to the side. The examiner can palpate over the ulnar side of the wrist at the distal point of the ulnar head. The extrinsic extensor tightness can be tested by maintaining the wrist in a neutral and passively extending the MCP joint and flexing the PIP point. The same test is repeated with the MCP joint when passively flexed. (Hill, E.J., 1963)
The second part of examination is the intrinsic muscles. This part is composed of the thenar muscle group, adductor pollicis (AdP), lumbrical, interrosseous muscles and the hpothenar muscle group. The thenar muscles are composed of the abductor pollicis brevis (APB), opponens pollicis (OP), and flexor pollicis brevis (FPB). These muscles can be evaluated by asking the patient to touch the thumb and small fingertips together for the nails to be parallel. They can be alternatively tested by asking the patient to place the dorsum of the hand flat on the table and raise the thumb of the surface by 90o. The examiner should be palpating the thenar muscles at this time to note wether they contract. The contralateral hand should also be examined in the same way to observe the variations in muscle mass and function. The AdP can be examined by making the patient to hold the paper forcibly between the hand and the radial side of the index proximal phalanx. The interosseous and lumbrical muscles should be tested by asking the patient to spread the fingers apart as the examiner keeps on palpating the first dorsal interosseous to observe whether it is contracting. Another alternative test is to lay the hand of the patient flat on the table and elevate the middle finger and radially and ulnarly deviate it. The hypothenar muscles is composed of the abductor digiti minimi (ADM), flexor digiti minimi (FDM), and opponens digiti minimi (ODM). They are evaluated by asking the patient to bring the small finger away from the other fingers. The intrinsic muscle tightnesss can be tested by holding the MCP joint in extension while the PIP joint is passively flexed by the examiner. (Hunt, T. R., & Wiesel, S. W. 2011)
The third part of examination is the nerves. The nerves are composed of the median nerve, ulnar nerve, radial nerve, and the sensory branches. They should be also examined to ensure that they are functioning normally without any defect. Any abnormality noticed should be recorded appropriately. (Jacobs, M. A., & Austin, N. M. 2003)
The fourth part of examination is sensibility. The normal skin should be moist. The dysfunction of the nerves may cause loss in sympathetic intervention in most of the distribution areas. This makes the skin to become dry. The finger should be tested by tactile gnosis by the moving and static two-point light touch discrimination test. The hand should be positioned on a flat table and make the patient to close his eyes. A disk-criminator or a bent paper clip should be used to measure the innervation density. The examiner should begin at 6mm distance between the prong and this should be preceded to higher and lower distances to determine the critical distance in which the patient indicates pain. (Lawton, J. N. 2013)
The fifth exercise is to test on the circulation. This should be done by noting the color of the skin and the fingernails as well as the blanching and flush of the nail-bed. The Allen test should be used in this case by following the following procedures: The ulner and radial arteries should be compressed first. The patient should be asked to make a fist, open and close it several times to exsanguinate the hand and then open the hand again into a relaxed position. The radial artery only should be released later. If the palm and fingers get filled with blood, then the radial artery is patent. Repeating the first and second steps, the ulnar artery should be released now. If the entire hand flushes, then the ulnar artery is pantent. (Miller, M. D., & Hart, J. A. 2011)
Working Diagnosis: The patient was diagnosed with a Bennet’s fracture. It has occurred from the ulnar base of the thumb metacarnal. (Sorock, G.S., Lombardi, D.A., Hauser, R.B., Eisen, E.A., Herrick, R.F. and Mittleman, M.A., 2001)
Brief management issues/referrals: This condition requires surgery that should be performed by the specialist wrist and hand surgeon. This should be followed by 4-6 week period of immobilization in a plaster cast. This operation involves the reduction of the bones which is a medical speak by putting them back in the right place. Fixation of the fracture can be done by making use of wires. (Strickland, J. W. 2005)
The therapist should mobilize the surrounding joints during the immobilization period to help in the restoration of the normal function of the other fingers. This should be followed by an exercise of wrist and hand strengthening.