Hand Special Tests

Intercarpal joints:

These are not synovial joints: thus, no resting position, close-packed position, or capsular pattern. Posterior Glide: Of 2,4,5: used to decrease the arch of the hand; Of 3: used to increase the arch of the hand Anterior Glide : Of 2,4, 5: used to increase the arch of the hand; Of 3: used to decrease the arch of the hand

Bunnell-Littler Test

(also called "intrinsic plus test"; for intrinsic muscle tightness vs PIP capsular restriction) This is a passive test. Stabilize the MCP in extension and passively move the PIP joint into full flexion. Measure PIP flexion. Then slightly flex the MCP and measure PIP flexion. Positive: the PIP moves into more flexion with the MCP flexed then with it extended, which indicates tight intrinsic muscles (if it does not move further and does not reach full ROM, consider capsular tightness)

Finkelstein Test

(for De Quervain's: tenosynovitis of the abductor pollicis longus and extensor pollicis brevis) Do this bilaterally because it may be tender even when tissue is normal. Pt sitting. The patient makes a fist with the thumb inside the fingers. The clinician stabilizes the forearm and passively ulnarly deviates the wrist. Positive: pain reproduction over abductor pollicis longus and extensor pollicis brevis

Gamekeeper's or Skier's Thumb Test

(for UCL & accessory collateral ligament tear, Sensitivity .94, unknown Specificity) Patient is sitting. A valgus stress is placed on the MCP joint of the thumb in full extension and 30 degrees flexion. Positive: an angulation of greater than 35 or 15 greater than the uninvolved side indicates tear/instability

Semmes-Weinstein Monofilament Testing

(for determining if normal light touch is present, for identifying CTS, Sensitivity .59-.98, Specificity .15-.86) The patient sits with eyes closed. A monofilament is applied in a perpendicular fashion to the surface of the hand until the monofilament begins to bend. The hand is divided into several areas: Normal: filament 2.83 MN is considered the "normal" light touch perception Positive: a positive test for CTS is when the patient with eyes closed cannot report which digit is receiving pressure

Weber/Moberg 2-Point Discrimination Test

(for determining threshold for discrimination, may help identify CTS, Sensitivity .06-.33, Specificity .99-1) The patient sits with eyes closed. A 2-point aesthesiometer tool or 2 paperclips are applied in a perpendicular fashion, to all the fingertips in a mixed series of 2 and 1 points for 5 consecutive applications (to each finger). The clinician repeats the test to find the minimal distance at which the patient can distinguish between 2 stimuli (threshold for discrimination), decreasing or increasing the distance between the points depending on the response of the patient. Normal: the patient should be able to recognize at least 4/5; normal discrimination is between 2-5 mm for fingertips and 3-7 mm for finger surfaces

Tinel's Sign

(for identifying carpal tunnel syndrome, Sensitivity .27, Specificity .91) Tap median nerve in volar wrist Positive: patient reports pain reproduction or paresthesias in distribution of the median nerve

Phalen's Test

(for identifying carpal tunnel syndrome, Sensitivity .34-.85, Specificity .74-.79) Patient places dorsal aspects of hands together, maintaining maximal wrist flexion for 60 seconds Positive: symptoms reproduced in median nerve distribution

Reverse Phalen's Test

(for identifying carpal tunnel syndrome, Sensitivity .42-.75, Specificity .35-.85) Patient places palmar aspects of hands together, maintaining maximal wrist extension for 60 seconds Positive: symptoms reproduced in median nerve distribution

Carpal Compression Test

(for identifying carpal tunnel syndrome, Sensitivity .83, Specificity .92) Patient seated with elbow flexed 30, forearm supinated, and wrist in neutral. Therapist places both thumbs over transverse carpal ligament (just distal to flexor wrist crease) and applies moderate pressure for 30 seconds. Positive: pain, paresthesia, or numbness is reproduced

Watson Test/Scaphoid Shift Test

(for instability of scaphoid, Sensitivity .69, Specificity .66) Patient's elbow stabilized on table with forearm in slight pronation. Grasp radial side of patient's wrist with thumb on palmar prominence of scaphoid. With other hand, grasp patient's hand at metacarpal level to stabilize wrist. Maintain pressure on scaphoid and move patient's wrist into ulnar deviation with slight extension and then radial deviate with slight flexion. Release pressure on scaphoid while wrist is in radial deviation and flexion. Positive: scaphoid shifts, test elicits a "thunk," or patient's symptoms are reproduced when scaphoid is released

Allen Test

(for radial/ulnar arterial supply) This test is more important diagnostically than it is for treatment decisions. It's not used as much now because Doppler studies have gained favor. Patient sitting with elbow bent and fingers pointing toward ceiling. Clinician compresses radial and ulnar arteries at the wrist. The patient should open and close the fist quickly. The clinician releases the pressure on one artery and observes the filling pattern of the vessels in the palm. The same is repeated for the other artery. Positive: blanching remains in the palm after pressure is released from the artery

Longitudinal Compression of Thumb

(for scaphoid fracture, Sensitivity .98, Specificity .98; for OA (consider mechanism of injury)) Hold patient's thumb and apply long axis compression through metacarpal bone into scaphoid Positive: pain reproduction

Snuff Box Tenderness

(for scaphoid fracture, Sensitivity 1.0, Specificity .98) Palpate base of anatomical snuff box Positive: pain reproduction

Supination Against Resistance

(for scaphoid fracture, Sensitivity 1.0, Specificity .98) •Hold patient's hand in hand-shake position and direct patient to resist supination of the forearm (patient tries to pronate, therapist tries to supinate patient's forearm) Pain: pain reproduction

Froment's Sign

(tests for paralysis of adductor pollicis via ulnar nerve palsy) Patient attempts to grasp paper between thumb with the IP extended and lateral border of index finger Positive: flexor pollucis longus substitutes here

Lunate Mobilization

Can dislocate, and when it does, the positional fault is usually in a volar direction. This problem can mimic carpal tunnel syndrome, so consider the patient's history: if the onset is sudden, consider the lunate; if the onset is slower, consider carpal tunnel. With wrist in neutral, place thumb over volar aspect of lunate and apply force in dorsal direction to help re-position fault.

MCP and IP joints:

Distraction: Promotes general mobility Posterior Glide: Promotes extension Anterior Glide: Promotes flexion Resting position: slight flexion Close-packed position: full extension Capsular pattern: flexion > extension

MidCarpal Distraction

General mobility same concepts as wrist mobility

Pisiform Mobilization

Grasp pisiform between thumb and index finger and move in all directions; mobilization of this bone in all directions might help in carpal tunnel syndrome or ulnar nerve entrapment at Guyon's canal

Hand Volume

Note: a difference of 10 ml is not significant - the dominant hand is often larger. Drop hand into water, with post positioned between the middle and ring finger. This "test" is perhaps more valuable in helping you measure the degree to which edema is changing between visits. (Reliability ICC = .99)

Figure-of-Eight Measurement for Assessing Edema

Place zero mark on distal aspect of ulnar styloid process. Tape measure brought across ventral surface of wrist to most distal aspect of radial styloid process. Then, tape is brought diagonally across dorsum of hand and over 5th MCP joint line, brought over ventral surface of MCP joints, and wrapped diagonally across dorsum to meet start of tape. Positive: difference side-to-side may indicate and quantify edema

Wrist Ulnar Glide

Radial Deviation Stabilization is provided AT the styloid processes, NOT in front of them. Forearm resting on treatment table and palm down. Place mobilizing hand on distal and proximal row of carpals and apply a gentle force in the ulnar direction with your forearm following the line of force. This can also be done with forearm in neutral position and applying ulnar force down toward floor. This technique is performed with a sweeping (crescent) motion.

Wrist Joint Radiocarpal & Ulnar Carpal

Resting position: 10 degrees wrist flexion and slight ulnar deviation Close-packed position: full extension with radial deviation Capsular pattern: equal limitation all directions

Trapezio-Metacarpal Joint (1st CMC) Resting position: Close-packed position: Capsular pattern:

Resting position: midway between thumb flexion/extension and midway between abduction/adduction Close-packed position: full opposition Capsular pattern: abduction > extension posterior glide: abduction anterior glide: adduction ulnar glide: flexion radial glide: extension distraction: general mobility

Midcarpal Joint

Resting position: neutral or slight flexion and slight ulnar deviation Close-packed position: extension with ulnar deviation Capsular pattern: equal limitations in all directions

1st MCP joint: Resting position: Close-packed position: Capsular pattern:

Resting position: slight flexion Close-packed position: maximal opposition Capsular pattern: flexion > extension Distraction: Promotes general mobility Volar/anterior glide: Promotes flexion Dorsal/posterior glide: Promotes extension

Wrist Radial Glide

Ulnar Deviation Stabilization is provided AT the styloid processes, NOT in front of them. Forearm resting on treatment table and palm down. Place mobilizing hand on distal and proximal row of carpals and apply a gentle force in the radial direction with your forearm following the line of force. This technique is performed with a sweeping (crescent) motion.

Wrist Anterior Glide

Wrist extension Stabilization is provided AT the styloid processes, NOT in front of them. Forearm resting on treatment table and palm down. Place mobilizing hand on distal and proximal row of carpals and apply a gentle force in the volar direction. It might be easier to position the patient sitting while the therapist stands. This allows the therapist to lock his/her elbow while delivering force from the shoulder.

MidCarpal Anterior Glide

extension same concepts as wrist mobility

MidCarpal Posterior Glide

flexion same concepts as wrist mobility

Murphy's Sign

for lunate dislocation) Have your patient make a fist, and check the third metacarpal joint: it should be higher than the 2nd and 4th metacarpals Positive: 3rd metacarpal joint is level with 2nd and 4th- the lunate might be dislocated

Wrist Distraction

general mobility Stabilization is provided AT the styloid processes, NOT in front of them. Forearm resting on treatment table and palm down. Place mobilizing hand on distal and proximal row of carpals and apply a gentle longitudinal pull distracting the carpals from the radius.

Wrist Posterior Glide

wrist flexion Stabilization is provided AT the styloid processes, NOT in front of them. Forearm resting on treatment table and palm up. Place mobilizing hand on distal and proximal row of carpals and apply a gentle force in the dorsal direction. It might be easier to position the patient sitting while the therapist stands. This allows the therapist to lock his/her elbow while delivering force from the shoulder, improving mechanical advantage.