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A Practical Guide to Clinical Medicine

A comprehensive physical examination and clinical education site for medical students and other health care professionals

Introduction Breast Exam Write Ups
History of Present Illness Male Genital/Rectal Exam The Oral Presentation
The Rest of the History The Upper Extremities Outpatient Clinics
Review of Systems The Lower Extremities Inpatient Medicine
Vital Signs Musculo-Skeletal Exam Clinical Decision Making
The Eye Exam The Mental Status Exam Physical Exam Lecture Series
Head and Neck Exam The Neurological Exam A Few Thoughts
The Lung Exam Putting It All Together Commonly Used Abbreviations
Cardiovascular Exam Medical Links References
Exam of the Abdomen    

The "daVinci Anatomy Icon" denotes a link to related gross anatomy pictures. DaVinci's Anatomy Symbol

Musculo-Skeletal Examination

Hand and Wrist

Normal function of the hand and wrist is obviously of great importance. A cursory review of this area is included in the Upper Extremity Examination. What follows is a description of commonly occurring pain syndromes and pathologic processes involving this region.

University of Washington, Hand Anatomy 1
University of Washington, Hand Anatomy 2

  1. Carpal Tunnel Syndrome

    Presentation and Anatomy: The median nerve travels through a narrow space when it crosses the wrist en route to the hand. Occasionally, this space becomes inadequate to accommodate the nerve, placing it under increased pressure. The precise reason why this occurs is not clear. Patients usually report some combination of the following:

    Examination:
  1. Ganglion Cyst

    Presentation and Anatomy: Idiopathic, spontaneous protrusion of joint fluid outside of the articular space. The cyst is painless and usually located on the dorsal aspect of the wrist.

    Examination:

  1. Dupuytren's Contracture Presentation and Anatomy: Thickening of the palmar fascia, which is usually painless and develops slowly over time. If pronounced, it may prevent the hand from being able to fully open.

    Examination:

  1. Heberden's Nodes

    Presentation and Anatomy: Bony excresences that cause deformity at the DIP joints of the fingers. Occurs slowly over time and is associated with Osteoarthritis. May affect many joints or only a few, though not usually symmetric. Similar protrusions at the PIP joints are called Bouchard's nodes.

    Examination:

  1. Trigger Finger

    Presentation and Anatomy: Flexor tendons connect muscles proximal to the wrist to the fingers. When the muscles shorten, they pull on the tendons, causing the fingers to flex. Occasionally, nodules/irregularities develop along the tendons, which then interfere with their smooth movement thru "pulleys" on the palm. Patients note difficulty flexing and extending the affected finger and lack of smooth movement. This is associated with a sensation of sudden freeing of the tendon ("triggering") when the irregularity slips through the pulley.

    Examination:

  1. Tenosynovitis of the Thumb (DeQuervain's type)

    Presentation and Anatomy: Repetitive abduction and adduction of the thumb can irritate the tendons of the extensor policis brevis and abductor policis longus muscles. When this occurs, any movement of the thumb (in particular, gripping) may cause pain at its base.

    Anatomy of extensor pollics brevis and longus

    Examination:

Selected Traumatic Injuries To The Hand (not in any way inclusive!)

  1. Boxer's Fracture

    Presentation: When a closed fist strikes a solid surface, the force may cause a break in the 5th metacarpal.

    Examination:

  1. Ulnar Collateral Ligament Disruption (gamekeeper's Thumb)


Ulnar Collateral Ligament Anatomy


gamekeeper Technique That Lead To UCL Injury
(Don't Worry, Bunny Used In Photo Is Not Real!)

 

The ulnar collateral ligament (UCL) is a strong band of tissue that connects the first phalanx of the thumb to the metacarpal bone along the ulnar side. Injury to this structure was first described in Scottish gamekeepers, who damaged the ligament as a result of the manner in which they killed rabbits. The head of the rabbit was grasped between thumb and first finger of one hand while they pulled on the rabbit's hind quarters with their other. This force chronically stressed the UCL, leading to weakening or frank rupture. After its initial description, it was quickly recognized that the ligament could be torn by any strong force that acutely abducts the extended thumb. Patient's are usually immediately aware that something is wrong, developing swelling, pain and instability at the metacarpal-phalangeal (MCP) joint . It has become a relatively common ski injury, occurring when a person falls on a hand that has a ski pole gripped between the thumb and forefinger.



Mechanism Of UCL Injury In Skiers


Examination is remarkable for swelling and pain at the MCP. The key maneuver assesses the degree of laxity at the joint. Place the thumb in extension (see picture below for positioning). Gently grasp the end of the thumb and apply an abducting force. If the UCL has been disrupted, you will be able to distract the thumb to a much larger degree then when compared to the normal side.


Picture on Left Demonstrates Normal Degree Of Laxity at the MCP Joint. Picture On The Right Demonstrates Markedly Increased Laxity Resulting From Disrupted UCL.

X-Ray Demonstrating gamekeeper's Fracture (Fragment At Proximal End Phalnax).

The ligament may become disrupted at it's insertion on the proximal phalanx, pulling away a small piece of bone that can be seen on x-ray.

Video Demonstrating UCL Disruption .


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Last updated 8/16/2008
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