Volar Central Wrist Pain- Conf 14 - Hand Foundation

[Pages:9]Volar Central Wrist Pain:

(Radial Volar and Ulnar Volar Zones) Reviewed by Alison Babula MS OTRL CHT Philadelphia Hand Center, 2015

Radial Volar Zone Anatomy: Palpation and Testing

Superficial Anatomy: Bones:

? Volar aspect of the radial styloid - tenderness may reflect volar radio-carpal ligament injury. Pain may be elicited with extension and radial deviation

? Scaphoid Tuberosity- radially deviate the wrist and palpate this bony prominence at the base of the thenar crease. Tenderness here or in snuffbox may indicate scaphoid disease. STT arthritis may produce palmar wrist pain

? Volar CMC joint - palpate adjacent to the trapezial ridge. Tender with CMC arthritis. Perform Grind Test to detect CMC arthritis- support thumb metacarpal and apply axial loading to CMC. The grind test has moderate reliability and accurately confirms the diagnosis of CMC osteoarthritis and identifies those who do not have CMC osteoarthritis.

Tendons: ? FCR: inserts to anterior surface of index metacarpal. Tenderness and fullness may indicate tenosynovitis. Resistance to FCR action will be painful with tenosynovitis ? Palmaris longus: passes in front of flexor retinaculum to become continuous with the palmar fascia. Oppose the thumb and the small finger and flex the wrist to palpate. NOTE: absence in 14-25% of the population

Nerves: ? Palmar cutaneous branch of MN: innervates skin over base of thenar eminence Tinels test - gently tap over the nerve. A positive test produces tingling and pain

Blood Supply: ? Radial artery - palpate radial to the FCR. Perform the Allen's test - The subject makes a tight fist and the examiner occludes both radial and ulnar arteries.2) Subject opens and closes the hand several times until the skin is white and blanched. 3) Release the radial artery and observe for flushing. If no flush may have occlusion. 4) Repeat the above to test the ulnar artery

Carpal Tunnel: Borders: ? Superficially: Transverse Carpal Ligament (TCL) or Flexor Retinaculum ? deep: carpal bones TCL insertion: ? medially: hook of the hamate and pisiform ? laterally: scaphoid and trapezium

? distal volar flexion crease crosses proximal end of scaphoid and pisiform. Proximal edge of TCL

Contents: 4 FDS tendons, 4 FDP tendons, FPL, Median nerve:

Phalen's Test

Tinel's Test

As described by Phalen, the test is

Using index finger and middle percuss

done by having patients rest their

the median nerve at the wrist level. A

elbows on the examination table

positive test produces tingling and pain

with their forearms perpendicular

that may radiate to the fingers.

to the floor and let their wrists drop

into flexion with gravity assistance,

NOT overpressure. A positive test

produces numbness and tingling in

the MN distribution within 60 secs.

Ulnar Volar Zone Anatomy: Palpation and Testing

Bones:

? Pisiform - a carpal sesamoid bone which lies within the fibers of the FCU. Palpate

this bony prominence at the base of the hypothenar eminence at the flexion crease of

the wrist. The pisiform overlies the triquetrum. When relaxed, the pisiform can be

moved against the triquetrum. Pain over the hypothenar eminence may indicate piso-

triquetral arthritis. Shear test for piso-triquetral arthritis - fingers dorsal to the

triquetrum and thumb on the pisiform. Push or rock the pisiform into the triquetrum.

A positive test elicits pain or crepitus.

? Hook of hamate - move slightly radial and distal to the pisiform (1-2 cm)

and ulnar to the thenar crease in the hypothenar eminence to palpate the hook of the

hamate. Tenderness may indicate fracture. May have associated ulnar nerve

symptoms with hamate fractures.

Tendons:

? Flexor Carpi Ulnaris- palpate on ulnar volar side of wrist. Flex and ulnarly deviate

the wrist while abducting small finger to palpate FCU. FCU inserts into pisiform, hamate and 5th metacarpal.

Nerves:

? Ulnar nerve and artery- travels between the hook of the hamate and the pisiform in

Guyon's canal. Perform Allen's and Tinel's test.

References: Merritt, MM, TS Roddey, C. Costello, and S. Olson. "Diagnostic Value of Clinical Grind Test for Carpometacarpal Osteoarthritis of the Thumb." Journal of Hand Therapy 23.3 (2010): 261-67.

Phalen GS: The carpal tunnel syndrome. Seventeen years' experience in diagnosis and treatment of 654 hands. J Bone Joint Surg Am 48:211-228, 1966

Skirven, Terri M. "Clinical Examination of the Wrist." Rehabilitation of the Hand and Upper Extremity. 6th ed. Vol. 1.: Elsevier, Philadelphia PA , chapter 6.

Valdes, K. LaStayo, P. "The value of provocative tests for the wrist and elbow: a literature review." Journal of Hand Therapy 26.1 (2013): 32-42

Wheeless, CR. Wheeless' Textbook of Orthopaedics

.

The value of provocative tests for the wrist and elbow: a literature review. Valdes, K. LaStayo, P. "The value of provocative tests for the

wrist and elbow: a literature review." Journal of Hand Therapy 26.1 (2013): 32-42

Table 1. Highly recommended provocative tests for the wrist & elbow

Test

Author, year

MacDermid5 study

score

Wrist neuropathy testing

Phalen's

LaJoie, 200514 8/12

Boland, 200915 9/12

Wainner, 200516 10/12

Amerifeyz,

8/12

200517

Tekeoglu, 200711 10/12

Mean

Tinel's

LaJoie, 200514 8/12

Wainner, 200516 10/12

Cheng, 200813 9/12

Amerifeyz,

8/12

200517

Tekeoglu, 200711 10/12

Mean

Modified compression test

Boland, 200915 9/12 Tekeoglu, 200711 10/12

Mean

+LR -LR

7.6

0.09

2.54 0.49

1.3

0.50

0.98 0.85

1.0

0.77

2.68 0.54

10.77 0.03

1.4

0.78

0.96 0.59

0.64 0.71

1.0

0.75

2.95 0.57

3.64 0.89

0.92 0.93

2.28 0.91

Test

Author, year

MacDermid5 study

+LR -LR

score

Wrist musculoskeletal pathology testing

Scaphoid shift

Wolfe, 199418 8/12

4.7

0.17

Wolfe, 199719 9/12

1.68 0

Prosser, 201120 10/12

2.88 0.28

LaStayo, 199521 10/12

1.78 0.55

Mean

2.76 0.25

Elbow neuropathology testing

Tinel

Cheng, 200813 8/12

53.99 0.46

Beekman, 200922 9/12

1.3

0.72

Mean

27.65 0.59

Elbow flexion

Beekman, 200922 9/12

1.0

0.99

Ochi, 201123

8/12

Infinity 0.64

Cheng, 200813 9/12

45.99 0.54

Mean

27.66 0.72

Bold numerical values are the resultant mean likelihood ratios. Table 2. Reasonable provocative tests for the hand, wrist & elbow

Test

Author, year

MacDermid5 study +LR

-LR

score

Wrist neuropathy testing

Symptom

Gok, 200824

9/12

relief maneuver

3.3

0.39

Flick

Gok, 200824

9/12

5.9

0.22

Wrist musculoskeletal pathology testing

Ulnar fovea Tay, 200727

11/12

7.06

0.05

Press test

Lester, 199526

7/12

Infinity 0

Series of 3

Christodoulou,

8/12

tests

199928

16.22 0.24

Test

Author, year

MacDermid5 study +LR

-LR

score

CMC grind Merritt, 201025

12/12

4.45

0.60

ECU synergy Ruland, 200829

9/12

2.9

0

Midcarpal

Prosser, 201120

10/12

2.67

Not

calculated

DRUJ

Prosser, 201120

10/12

1.79

0.30

Elbow neuropathy testing

Scratch collapse

Cheng, 200813

9/12

68.99 0.31

Ulnar nerve Beekman, 200922 9/12 thickening

2.2

0.82

Shoulder IR Ochi, 201123

8/12

Infinity 0.19

Crossed

Earle, 198031

8/12

fingers

Infinity 0.36

Elbow musculoskeletal pathology testing

Moving

O'Driscoll, 200530 9/12

valgus stress test

Infinity 0.05

+LR = positive likelihood ratio; -LR = negative likelihood ratio; DRUJ = distal radioulnar joint; CMC = carpometacarpal; IR = internal rotation.

Table 3. Neutral/no recommendation provocative tests for the wrist & elbow

Test

Author, year

MacDermid5

+LR -LR

study score

Wrist neuropathology testing

Carpal compression test Amirfeyz,

7/12

201140

0.80 0.83

Goloborod'ko, 7/12 200432

0.88 0.90

Wainner, 200516 10/12

0.91 1.2

El Miedany,

7/12

200841

0.61 2.16

Test

Author, year

MacDermid5

study score

Mean

Tourniquet test

Amirfeyz,

7/12

201140

Goloborod'ko, 7/12 200432

Mean

Hand elevation test

Amirfeyz,

7/12

201140

Amirfeyz,

8/12

200517

Mean

Phalen's wrist extension Goloborod'ko, 7/12 200432

El Miedany,

7/12

200841

Yoshida, 201034 7/12

Mean

Tanzer's

Goloborod'ko, 7/12 200432

Postural provocation Goloborod'ko, 7/12 200432

Constant pressure on Goloborod'ko, 7/12

lunate

200432

Pneumatic compression Tekeoglu,

test

200711

10/12

Okutsu

Yoshida, 201034 7/12

Upper limb tension test Wainner, 200516 10/12 Part A

+LR -LR

0.80 1.27 0.72 0.90

0.95 0.87

0.83 0.89 0.92 0.99

0.98 0.88

0.95 0.94 0.92 0.88

0.64 1.65

1 Unable to calculate

0.85 1.27 0.91 0.79

0.98 0.98

0.98 0.98

0.98 0.83

1.0 Unable to calculate

0.91 1.2

Test

Author, year

MacDermid5

+LR -LR

study score

Upper limb tension test Wainner, 200516 10/12 Part B

0.86 1.9

Upper limb neurodynamic test

Vanti, 201135 9/12

1.81 0.65

Combined wrist flexion Cheng, 200813 9/12 & carpal compression

0.98 0.65

Scratch collapse test Cheng, 200813 9/12

0.99 0.73

Phalen's combined with Bilkis, 201136 6/12 sensory testing

1.0 0.74

Wrist musculoskeletal pathology testing

Ulnomenisco-triquetral LaStayo, 199521 10/12 dorsal glide

1.2 0.77

Ballottement

LaStayo, 199521 10/12

1.12 0.83

Lunotriquetral test

Prosser, 201120 10/12

1.03 0.80

GRIT

Prosser, 201120 10/12

1.12 0.83

Ulnocarpal stress test Nakamura,

7/12

199737

1.0 Unable to calculate

Elbow neuropathology testing

Ulnar nerve tenderness Beekman,

9/12

200922

1.6 0.85

Elbow musculoskeletal pathology testing

Chair sign

Regan, 200638 4/10

0.87 Unable to calculate

Push-up sign

Regan, 200638 4/10

0.87 Unable to calculate

Tabletop relocation

Arvind, 200639 4/10

1.0 Unable to calculate

Bold numerical values are the resultant mean likelihood ratios. +LR = positive likelihood ratio; -LR = negative likelihood ratio; GRIT = gripping rotatory impaction test.

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