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Osteopathy Practical Technique Bridging Course

Session 4: Elbow, wrist and hand

Part A: Introduction to the surface anatomy of the elbow and wrist region

References:

Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 6 th Ed. Philadelphia:Wolters Kluwer/Lippincott Williams & Wilkins. 2010. Ch 6

Lumley JSP. Surface Anatomy. The anatomical basis of clinical examination. 4 th Ed. Edinburgh:Churchill Livingstone. 2008. Ch 7

Biel A. Trail Guide to the Body. 4 th Ed. Boulder:Books of Discovery. 2010. Ch 3

Hoppenfeld S. Physical Examination of the Spine and Extremities. New Jersey:Prentice Hall.

1976

Chila AG. Editor. Foundations of Osteopathic Medicine. 3 rd Ed. Philadelphia:Lippincott

Williams & Wilkins. 2011. Ch 43

Nordin M and Frankel VH. Basic Biomechanics of the Musculoskeletal System. Philadelphia:

Lippincott Williams & Wilkins. 2012 Ch 13, 14

Structures of the elbow, wrist and hand that need to be known

The following list contains the structures to be covered in this lecture and associated practical class. You will need to use the above references, or other suitable texts, to outline the details required. For muscles and ligaments you will need to know their origin*, insertion*

and action.

Some of the structures have been covered in previous lectures.

*Note the origin and insertion may be known as proximal, distal, superior or inferior attachment in some texts.

Bones:

Distal humerus, radius, ulnar, carpal bones – tra pezium, trapezoid, capitate, hamate, pisiform, triquetrum, lunate, scaphoid, metacarpals, phalanges

Landmarks:

medial epicondyle, lateral epicondyle, head of radius, radial tuberosity, olecranon, cubital fossa, anatomic snuff box/radial fossa, radial styloid process, Lister’s tubercle/tubercle of the radius, tubercle of the scaphoid, ulnar styloid process, hook of hamate

Muscles:

biceps brachii, triceps brachii, wrist extensor group and flexor group, pronator teres, brachioradialis, brachialis, thenar eminence, hypothenar eminence,

Ligaments:

extensor and flexor insertions, carpal tunnel

Pulses:

radial pulse

Nerve:

ulnar nerve at elbow

Palpation of the Distal Humerus

Patient position:

Practitioner position: standing at the side of the table, level with the patient’s pelvis or lower abdomen and facing toward the patient. If seated, stand to one side, facing the patient.

supine or seated

Applicator:

pad of the fingers

Procedure:

a. place the patient’s elbow into flexion, approximately 90 degrees.

b. hold the patient’s hand or wrist with your non-palpating hand

c. locate the olecranon process, bony point of elbow, and move your fingers

to one side, either medially or laterally

d. as you move away from the olecranon process you will feel a dip and as

you proceed you will encounter the round shaped epicondyle of the humerus.

e. let the finger pads explore the rounded shape of the epicondyle in all

directions

f. bring the fingers back to the most lateral or medial aspect of the

epicondyle and then let the fingers move superiorly until they slide off the rounded epicondyle and encounter the bony ridge of the supracondylar ridge

g. the supracondylar ridge can be felt by letting the finger pad roll over its

edge

h. repeat from ‘c’ and palpate the opposite epicondyle

Palpation of the Radius

Patient position:

Practitioner position: standing at the side of the table, level with the patient’s pelvis or lower

abdomen and facing toward the patient. If seated, stand to one side, facing the patient.

supine or seated

Applicator:

pad of the fingers

Procedure:

a. place the patient’s arm in a neutral or slightly flexed position

b. locate the lateral epicondyle and let the fingers move distally until you

encounter the joint line between the humerus and the head of the radius

c. the joint line between the humerus and the head of the radius can be felt

more easily on the posterior surface as there is less tissue to palpate through

d. continue to move the fingers distally, a small distance, until you feel the

radial head. The radial head is less than one centimetre wide and is distinct from the shaft of the radius as it projects further outwards.

e. after palpating as much of the radial head as possible allow the fingers to

continue to move distally along the shaft of the radius

f. note the muscles that cover the radius over its proximal half and how the

shaft of the radius becomes more easily palpated distally as there are less tissues covering it.

g. continue to palpate along the shaft until you come to end.

h. palpate the distal end of the radius between the thumb and index finger

and bring them together over the lateral aspect of the distal radius until they

encounter the styloid process of the radius

i. move the hand in a medial to lateral direction, and back. Palpate how the

styloid process becomes more palpable when the hand is moved medially and how the tissues relax in the lateral position (movement toward the thumb)

j. move the finger pad to the posterior surface of the distal radius palpate the bony prominence of Lister’s tubercle.

Palpation of the Ulnar

Patient position:

Practitioner position: standing at the side of the table, level with the patient’s pelvis or lower abdomen and facing toward the patient. If seated, stand to one side, facing the patient.

supine or seated

Applicator:

pad of the fingers

Procedure:

a. place the patient’s elbow in flexion

b. hold the wrist of hand of patient with the non-palpating hand

c. place the palpating finger pads over the bony point of the elbow, the

olecranon process

d. explore the olecranon process

e. let the fingers slide off the proximal end of the olecranon process and

gently sink through the triceps muscle toward the olecranon fossa

f. bring the fingers back over the olecranon onto the shaft of the ulnar.

g. palpate distally along the ulnar, noting that the posterior and lateral

aspects are more easily palpated as they have less muscle covering them.

h. at the distal end of the ulnar the bone will broaden and this is known as the

head of the ulnar

i. palpate the head of the ulnar and the styloid process on the lateral and

most distal aspect of the ulnar

j. as with the distal end of the radius, move the hand or wrist, in a medial-

lateral direction and note the change in access to the styloid process and tissue tension.

Palpating the Carpal Bones (Wrist)

Patient position:

Practitioner position: standing at the side of the table, level with the patient’s pelvis or lower

abdomen and facing toward the patient. If seated, stand to one side, facing the patient.

spine or seated

Applicator:

pad of the fingers or thumb

Procedure:

a. place the thumb pads over the posterior surface of the wrist and the finger pads on the anterior surface of the wrist

b. gently palpate the wrist, noting the pebble like surface of the carpal bones

as your fingers move over their surface

c. then passively move the patient’s wrist and note the way that the carpal

bones move to accommodate this movement and how the different bones become more easily palpated in different positions

d. now find the radial styloid process with the pad of thumb or index finger

and slide it distally until it moves into the hollow between the styloid process and the base of the thumb

e. move the hand in a medial direction (toward the little finger) and feel the

scaphoid bone’s lateral surface press against the palpating finger pad.

f. move your fingers over the palmar and dorsal surface of the scaphoid. If

you lose contact with it find the distal end of the radius and move distally onto the surface of the scaphoid

g. once you have found and palpated the scaphoid, move the fingers distally

until they encounter the trapezium.

h. the trapezium has a close relationship with the metacarpal bone of the

thumb and it is sometimes easy to confuse the trapezium with the proximal

end of the metacarpal bone.

i. on the palmar surface, palpate the scaphoid and trapezium and gently

palpate for the tubercles of these bones. Flexing the wrist slightly may help to loosen the covering tissues so that the tubercles are more easily palpated.

j. the trapezoid is located medial to the trapezium and proximal to the second metacarpal bone. It is not as easy to palpate as some of the other carpal bones

k. on the dorsal surface, locate the proximal end of the third metacarpal bone

and let the finger pad slide proximally.

l. the finger pad will fall into a hollow and this is where the lunate and

capitate lie

m. passively flex the wrist and feel how the capitate moves under the finger

or thumb pad

n. move the finger/thumb proximally so that it comes off the capitate and you

can feel the lunate move under your fingers on passive flexion

o. turn the patient’s hand so that its palmar surface is facing you, and move

the fingers toward the ulnar aspect of the wrist

p. locate the creases in the wrist and place your finger pad just distal to this,

maintaining the position on the ulnar edge of the wrist

q. gently circle the pad of your finger over this aspect of the wrist until you

encounter the pebble like pisiform bone

r. locate the styloid process of the ulnar and slide the finger pad along the

edge in a distal direction until you palpate the medial edge of the triquetrum in the dip between the ulnar styloid process and the fifth metacarpal bone.

s. locate the pisiform bone and move the applicator in a distal and lateral

direction from the pisiform. The hamate lies in this position deep to the hypothenar eminence. The hook of the hamate lies lateral and distal to the

pisiform. It is palpable through the muscles of the hypothenar eminence.

Palpation of the Metacarpals

Patient position:

Practitioner position: standing at the side of the table, level with the patient’s pelvis or lower abdomen and facing toward the patient. If seated, stand to one side, facing the patient.

supine or seated

Applicator:

pad of the fingers, thumbs

Procedure:

a. place the finger or thumb pads on the dorsal surface of the hand

b. let the fingers palpate along the shaft of each metacarpal bone, from the

base at the proximal end to the head at the distal end

c. note that the space between the carpal bones is wider in the middle of the

length and that you can gently separate the heads of the metacarpal bones.

d. palpating the palmar aspect of the metacarpal bones takes more

concentration as there are more tissue layers to palpate through.

e. remember to include the metacarpal of the thumb which lies distal to the

carpal bones on the radial side of the hand

Palpation of the Phalanges

Patient position:

Practitioner position: standing at the side of the table, level with the patient’s pelvis or lower

abdomen and facing toward the patient. If seated, stand to one side, facing the patient.

Applicator:

supine or seated

pad of the fingers, thumbs and palm of hand

Procedure:

a. Locate the head of one of the metacarpals and move distally until the base of the proximal phalange is palpated

b. continue moving distally until the head of the proximal phalange is

reached.

c. continue distally and palpate the base and head of the middle phalange

d. continue distally and palpate the distal phalange.

e. palpate the joint between each phalange

f. repeat steps a-e for each finger and the thumb. Note the thumb has only a proximal and distal phalange

Palpation of the Cubital Fossa

Patient position:

Practitioner position: standing at the side of the table so that you are at the level of the patient’s arm.

supine or seated

Applicator:

pad of the fingers

Procedure:

a. locate the elbow skin folds, as they form a line between the two epicondyles of the humerus. This is the superior border

b. locate the brachioradialis’s medial border

c. locate the lateral border of the pronator teres

d. these three structures form the borders of the cubital fossa

e. let the pad of your finger sink into this fossa

f. note how the biceps tendon divides the fossa into two parts

g. the pulse of the brachial artery can be palpated medial to the biceps

tendon

h. the median and musculocutaneous nerves also lie within this fossa, medial

to the brachial artery. See if you can palpate their tube like structure

i. in the floor of the fossa lies the brachialis, superior part, and the supinator

(inferior aspect)

Palpation of the Anatomical Snuff Box

Patient position:

Practitioner position: standing at the side of the table, level with the patient’s pelvis or lower abdomen and facing toward the patient. If seated, stand to one side, facing the patient

supine or seated

Applicator:

pad of the index finger or thumb

Procedure:

a. Place the patient’s hand so that the dorsal surface faces you

b. have the patient extend their thumb; moves toward the radius

c. find the styloid process of the radius

d. move the finger distally so that it rests between the two tendons of the

thumb (extensor pollicis longus tendon on one side and the extensor pollicis brevis and abductor pollicis longus tendon on the other)

e. this space is the anatomical snuff box

Palpation of the Wrist Extensor Group of Muscle

Patient position:

Practitioner position: standing at the side of the table, level with the patient’s pelvis or lower

abdomen and facing toward the patient. If seated, stand to one side, facing the patient

seated or prone

Applicator:

pad and flat of the finger or thumb

Procedure:

a. at the elbow of the patient locate the proximal anterolateral aspect of the radius

b. lay your fingers over this part of the forearm and ask the patient to extend

their wrist and feel the muscles contract under the fingers

c. ask the patient to bring the wrist back to neutral and feel the muscles relax

under your fingers

d. move your fingers proximally to the lateral epicondyle and explore the

origin of the extensor group of muscles. To assist you can ask your patient to

slowly extend and flex the wrist.

Origin:

lateral epicondyle of humerus – common extensor origin

Insertion:

dorsal aspect of base of 3 rd and 5 th metacarpal, extensor expansions of

Action:

medial four digits, and 5 th metacarpal. extends wrist and metacarpophalangeal joints

Palpation of the Wrist Flexor Group of Muscle

Patient position:

Practitioner position: standing at the side of the table, level with the patient’s pelvis or lower

abdomen and facing toward the patient. If seated, stand to one side, facing the patient

supine or seated

Applicator:

pad of flat of the finger, thumb

Procedure:

a. at the elbow the of patient locate the proximal anteromedial aspect of the ulnar

b. lay your fingers over this aspect of the forearm and ask the patient to flex

their wrist and feel the muscles contract under your fingers c. ask the patient to bring the wrist back to neutral and feel the muscles relax under your fingers

d. move the fingers proximally to the medial epicondyle and explore the

origin of the extensor group of muscles. To assist you can ask your patient to

slowly flex and extend the wrist.

Origin:

medial epicondyle of humerus - common flexor origin

Insertion:

base of 2 nd metacarpal; distal half of flexor and apex of palmar aponeurosis;

Action:

pisiform, hook of hamate, 5 th metacarpal flexes wrist

Palpation of the Pronator Teres Muscle

Patient position:

Practitioner position: standing at the side of the table, level with the patient’s pelvis or lower abdomen and facing toward the patient. If seated, stand to one side, facing the patient

supine or seated

Applicator:

pad of the finger or thumb

Procedure:

a. hold your patient’s wrist or hand with your non-palpating hand

b. ask your patient to flex their elbow to 90 degrees and resist the movement

when 90 degrees is reached

c. the tendon of biceps brachii should become obvious

d. place your palpating finger on the tendon of biceps brachii and move the

finger medially and distally so that the finger slips off the tendon into the

space between the tendon and the flexor group of muscles

e. let your finger sink into this space until you encounter the medially running

fibres of the pronator teres f. to enhance the awareness of the muscle ask you patient to pronate their hand while you resist the movement. This will cause the pronator teres to contract and help identify the muscles position.

Origin:

coronoid process and medial epicondyle of humerus

Insertion:

middle convexity of lateral surface of radius

Action:

pronates and flexes forearm (at elbow)

Palpation of the Thenar Eminence

Patient position:

Practitioner position: standing at the side of the table, level with the patient’s pelvis or lower abdomen and facing toward the patient. If seated, stand to one side, facing the patient

supine or seated

Applicator:

pad of the finger, thumb

Procedure:

a. place the patient’s hand so that the palm of the hand is facing up

b. locate the shaft of the first metacarpal bone of the thumb and palpate the

muscle mass over the metacarpal bone

c. move the palpating fingers so that you palpate the borders of the muscles

and follow the muscles to their insertions on the phalange of the thumb and

then to the origin near the capitates bone

d. to enhance the muscles have your patient move their thumb toward the

little finger

The thenar eminence contains the abductor pollicis brevis, flexor pollicis brevis, opponens pollicis and adductor pollicis.

Palpation of Hypothenar Eminence

Patient position:

Practitioner position: standing at the side of the table, level with the patient’s pelvis or lower

abdomen and facing toward the patient. If seated, stand to one side, facing the patient

supine or seated

Applicator:

pad of the finger, thumb

Procedure:

a. place the patient’s hand so that the palm of the hand is facing up

b. locate the base of the fifth metacarpal bone and palpate the muscle mass

over the medial aspect of the heel of the hand and as it goes up the shaft of

the fifth metacarpal bone

c. palpate medially where it creates a slight indent that separates the thenar

eminence from the hypothenar eminence

The hypothenar eminence consists of the abductor digiti minimi, flexor digiti minimi brevis and opponens digiti minimi

Palpation of the Carpal Tunnel

Patient position:

Practitioner position: standing at the side of the table, level with the patient’s pelvis or lower abdomen and facing toward the patient. If seated, stand to one side, facing the patient

supine or seated

Applicator:

pad of the finger or thumb

Procedure:

a. place your palpating finger over the anterior or palmar surface of the wrist

b. sink just below the layer of the skin and move the finger in a distal

direction

c. let the finger sink deeper until you feel the tendons as they run across the

anterior surface of the carpal bones

d. let the finger come off the tendons a small amount and see if you can feel

the fibres of the retinacula as they run over the top of the tendons

e. explore the area of the carpal tunnel; the different layers, tissues, direction

of fibres and their relationship with the muscles at the heel of the hand

Palpation of the Radial Pulse

Patient position:

Practitioner position: standing at the side of the table, level with the patient’s pelvis or lower

abdomen and facing toward the patient. If seated, stand to one side, facing the patient

supine or seated

Applicator:

pad of the fingers

Procedure:

a. have the patient rest their forearm on a pillow, their thigh, or any other position so that the wrist is easily accessible

b. place the pads of two fingers on the radial side of the forearm, just

proximal to the wrist

c. feel for the most lateral tendon and let the finger pads slide off it laterally

d. gently press toward the radial bone until you feel the pulse under the finger

pads

Palpation of the Ulnar Nerve at the Elbow

Patient position:

Practitioner position: standing at the side of the table so that you are at the level of the patient’s elbow. Standing to the side of the patient facing them

seated or supine

Applicator:

pad of the fingers

Procedure:

a. have the patient slightly flex their elbow and support the arm with your non-palpating hand

b. ensure that your supporting hand does not cover the medial epicondyle of

the humerus (hold the arm either above or below the elbow)

c. locate the medial epicondyle with your palpating finger pad

d. move the finger so that it moves posteriorly until it feels a dip. This dip is

the groove in the humerus that the ulnar nerve lies in

e. let your finger pad sink through the layers until it encounters the tube like

structure of the ulnar nerve

f. gently move your finger across the nerve. If you press too hard your

patient will feel very uncomfortable as the ulnar nerve is irritated. Remember what it is like when you hit your ‘funny bone’. This is the ulnar nerve being hit and the sensation of a nerve being irritated

PART B:

Active Range of Motion of the Elbow, Wrist and Hand/Fingers

Active Range of Motion of the Elbow, Wrist and Hand/Fingers

Patient:

seated

Practitioner:

standing in front of the patient.

Applicator:

Procedure:

a.

ask the patient to flex both of their glenohumeral joints so that they raise

their arms, palm facing the ceiling. A 45 degree angle is sufficient as this will allow the elbow to be flexed and extended without the table getting in the

way. It is common practice to assess both arms at the same time during active range of motion as it allows you to observe for symmetries between the two arms simultaneously.

b. ask the patient to bring their hand toward their shoulder and observe

flexion of the elbow

c. ask the patient to straighten their arms and observe extension. Look for

signs of hyper extension which is when the forearm drops below the level of

the arm (humerus). Up to 5 degrees of extension past the neutral point is within normal range; anything more than this falls into the category of

hyperextension.

d. ask the patient to return their arm to their side and have their elbows

flexed to 90 degrees. This position ensures that you observe supination and

pronation and not internal and external rotation of the glenohumeral joint (which occurs when the elbow is straight or nearly straight)

e. ask the patient to turn their palms down to the floor for pronation and turn

their palms up to the ceiling for supination. You may wish to repeat this

motion a few times to ensure you have a clear idea of any dysfunction

present.

f. next ask the patient to bring their hand up toward the ceiling and down

toward the floor, moving only at the wrist. This assesses wrist flexion and extension.

g. with the palms facing toward the floor, ask the patient to move their hands

so that the hand moves inwards for radial deviation and outwards for ulnar deviation. The hand should stay parallel to the floor and not include any supination or pronation movements.

h. with the palm facing toward the ceiling ask the patient to make a fist. This

assesses the ability of the metacarpophalageal joint, the proximal interphalangeal joint and the distal interphalageal joint to flex.

i. ask the patient to open their closed fist and stretch their fingers back as

far as they will go. This is extension of the metacarpophalangeal joint, as well as the interphalangeal joints.

j. to assess the thumb. Ask the patient to move the thumb away from the

hand for abduction and bring it back toward the hand for adduction. Ask the patient to bring the thumb to the ceiling for palmar abduction and back toward the hand for palmar adduction. Ask the patient to circle their thumbs. And finally ask them to bring their thumb and little finger (5 th digit) together.

Passive Range of Motion to the Elbow

Patient:

seated

Practitioner:

standing in front of the patient.

Applicator:

hand, fingers

Procedure:

a.

place your palpating hand (one furthest from patient) over the posterior

aspect of the elbow. Cup the elbow so that you can palpate as much of it as

possible

b. with your other hand hold the patient’s wrist or distal forearm

c. to assess elbow flexion, bring the patient’s hand toward their shoulder

d. bring the hand away from the shoulder and continue this motion until you

feel the olecranon process meet the bone of the olecranon fossa of the humerus. A ‘normal’ range of motion for extension past the neutral point is 0-5 degrees. Some people will have hypermobile elbow joints and this will delay the olecranon process fitting into the olecranon fossa. Sometimes you might want to gently ‘bounce’ the elbow into extension. You can do this by

placing the lateral aspect of the second digit/metacarpal bone just proximal to the olecranon fossa and gently pushing anteriorly and taking the pressure off a few times in quick succession. While doing this you are lightly supporting the forearm so that there is no jarring and you can maintain control of the patient’s limb.

e. ask the patient to move their arm by their side and flex their elbow to

90 degrees, or move the patient’s upper extremity into this position yourself.

f. with your palpating hand, cup the elbow and with your non-palpating hand hold your patient’s hand

g. use your hand to turn the patient’s forearm, or hand, toward the floor to

assess pronation and toward the ceiling to assess supination

h. repeat step ‘g’ while palpating the radial head. Assess how the radial

head moves in relation to the ulnar and humerus. Hold the radial head between your thumb and index finger

i. to assess medial and lateral gapping of the elbow, place the patient’s

forearm between the side of your body and your arm (medial aspect facing the ceiling). Have slight flexion of the patient’s elbow

j. place your hands on either side of the patient’s forearm, just distal to the

elbow joint

k. for medial gapping, gently push against the patient’s proximal radius. For

lateral gapping, gently push against the patient’s ulnar. Note: it is important to be careful with the amount of force you use as too much force can injure tissues

Passive Range of Motion of the Wrist

Patient:

seated

Practitioner:

standing in front of the patient.

Applicator:

hand, fingers

Procedure:

a.

place your hand over the distal radius and ulnar and wrap your fingers

and thumb around the proximal wrist

b. place your other hand over the proximal carpal bones and wrap your

fingers and thumb around the wrist. Your two hands should be almost touching

c. gently push against the carpal bones while you gently pull posteriorly on

the distal ulnar and radius

d. reverse the motion so that the carpal bones move posteriorly and the

radius/ulnar move anteriorly

e. repeat steps ‘c’ and ‘d’ a few times

f. move both hands distally so that the proximal hand is over the proximal

carpal bones and the distal hand is over the distal carpal bones.

g. introduce the posterior/anterior gliding, or shearing, motion between the

two rows of the carpal bones. This motion will have a greater degree of motion, however, it is important to maintain as light a pressure or force as possible so that you do not strain the ligaments in this region

h. move the hands distally so that the proximal hand lies over the distal row

of carpal bones and the distal hand lies over the proximal metacarpal bones

i. there will not be a lot of motion at this joint lines so do not put too much

force through this joint line as you introduce the posterior/anterior glide.

j. change your hold so that your palpating hand is over the wrist and your

other hand contacts the patient’s hand. You can hold the patient’s hand as if you are going to shake it, or clasp it between your fingers and thumb – either

anteriorly/posteriorly or contact on either side of the hand (shaft of 2 nd and 5 th metacarpal bones). You can also change your hand hold to more efficiently move the patient’s wrist if need be.

k. introduce ulnar and radial deviation at the wrist. This can be done with the

forearm in pronation or supination. Be careful to ensure that the hand is

moved in the same plane and you do not introduce flexion or extension into the wrist.

l. introduce flexion and extension to the wrist. You may need to adjust the

position of the hand palpating the wrist so that it does not interfere with the movement. This may mean having a light grip of the wrist or moving

proximally so that full range of motion is possible.

m. introduce a circular, or circumduction, motion to the wrist. Go in one

direction and then the other

n. repeat the above for the other wrist.

Passive Range of Motion of the Hand/Fingers and Thumb

Patient:

seated

Practitioner:

standing in front of the patient.

Applicator:

hand, fingers

Procedure:

a.

place your thumb on the posterior aspect of the 2 nd metacarpal bone and

the other thumb on the posterior aspect of the 3 rd metacarpal bone. Wrap your fingers around the hand and let your fingers lie approximately under the

2 nd and 3 rd metacarpal bones

b. press with one thumb and lift with the other to create a shearing between

the two metacarpal bones. Then reverse the direction and feel the movement.

c. repeat this process with the 3 rd to 5 th metacarpal bones.

d. hold the patient’s hand with one hand to stabilize it

e. with the other hand place a finger on either side of the patient’s 2 nd

proximal phalanx and bring the phalanx toward the palm of the patient’s hand

to assess flexion at the metacarpophalangeal joint. Move the phalanx away from the patient’s palm and assess extension at the metacarpophalangeal joint

f. put your fingers on the side of the middle phalanx and move the middle

phalanx in flexion at the proximal interphalangeal joint. Return the phalanx to

starting point to assess extension. Note: there is little extension beyond the neutral position for this joint

g. put your fingers on the side of the distal phalanx and move the distal

phalanx in flexion at the distal interphalangeal joint. Return the phalanx to

starting point to observe extension. You can move the distal phalanx beyond the neutral point to observe the full range of extension at this joint

h. hold the patient’s 2 nd digit and move it to one side and then the other

introducing abduction and adduction at the metacarpophalangeal joint (this

could also be called ulnar and radial deviation).

i. hold the patient’s 2 nd digit and introduce circumduction at the

metacarpophalangeal joint (by taking the digit into flexion, abduction,

adduction and extension). Introduce circumduction into the opposite direction.

j. repeat steps ‘f – i’ for all four fingers

k. hold the patient’s thumb on either side.

l. move the thumb away from the hand in an palmar abduction/adduction,

abduction/adduction and circumduction motion at the 1 st carpometacarpal

joint.

(One motion at a time.)

m.

introduce flexion and extension at the metacarpophalangeal joint, and

interphalangeal joint of the thumb