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. 6th Ed. Philadelphia:Wolters
Kluwer/Lippincott Williams & Wilkins. 2010. Ch 6
Lumley JSP. Surface Anatomy. The anatomical basis of clinical examination. 4th Ed.
Edinburgh:Churchill Livingstone. 2008. Ch 7
Biel A. Trail Guide to the Body. 4th 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. 3rd 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 trapezium, 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, Listers 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: supine or seated
Practitioner position: standing at the side of the table, level with the patients pelvis or lower
abdomen and facing toward the patient. If seated, stand to one side, facing the patient.
Applicator:
pad of the fingers
Procedure:
a. place the patients elbow into flexion, approximately 90 degrees.
b. hold the patients 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: supine or seated
Practitioner position: standing at the side of the table, level with the patients pelvis or lower
abdomen and facing toward the patient. If seated, stand to one side, facing the patient.
Applicator:
pad of the fingers
Procedure:
a. place the patients 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 Listers tubercle.

Palpation of the Ulnar

Patient position: supine or seated
Practitioner position: standing at the side of the table, level with the patients pelvis or lower
abdomen and facing toward the patient. If seated, stand to one side, facing the patient.
Applicator:
pad of the fingers
Procedure:
a. place the patients 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 mediallateral direction and note the change in access to the styloid process and
tissue tension.

Palpating the Carpal Bones (Wrist)

Patient position: spine or seated
Practitioner position: standing at the side of the table, level with the patients pelvis or lower
abdomen and facing toward the patient. If seated, stand to one side, facing the patient.
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 patients 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 bones 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 patients 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: supine or seated
Practitioner position: standing at the side of the table, level with the patients pelvis or lower
abdomen and facing toward the patient. If seated, stand to one side, facing the patient.
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: supine or seated
Practitioner position: standing at the side of the table, level with the patients pelvis or lower
abdomen and facing toward the patient. If seated, stand to one side, facing the patient.
Applicator:
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: supine or seated
Practitioner position: standing at the side of the table so that you are at the level of the
patients arm.
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 brachioradialiss 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: supine or seated
Practitioner position: standing at the side of the table, level with the patients pelvis or lower
abdomen and facing toward the patient. If seated, stand to one side, facing the patient
Applicator:
pad of the index finger or thumb
Procedure:
a. Place the patients 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: seated or prone
Practitioner position: standing at the side of the table, level with the patients pelvis or lower
abdomen and facing toward the patient. If seated, stand to one side, facing the patient
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:
Insertion:
Action:

lateral epicondyle of humerus common extensor origin

dorsal aspect of base of 3rd and 5th metacarpal, extensor expansions of
medial four digits, and 5th metacarpal.
extends wrist and metacarpophalangeal joints

Palpation of the Wrist Flexor Group of Muscle

Patient position: supine or seated
Practitioner position: standing at the side of the table, level with the patients pelvis or lower
abdomen and facing toward the patient. If seated, stand to one side, facing the patient
pad of flat of the finger, thumb
Applicator:
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:
Insertion:
Action:

medial epicondyle of humerus - common flexor origin

base of 2nd metacarpal; distal half of flexor and apex of palmar aponeurosis;
pisiform, hook of hamate, 5th metacarpal
flexes wrist

Palpation of the Pronator Teres Muscle

Patient position: supine or seated
Practitioner position: standing at the side of the table, level with the patients pelvis or lower
abdomen and facing toward the patient. If seated, stand to one side, facing the patient
pad of the finger or thumb
Applicator:
Procedure:
a. hold your patients 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:
Insertion:
Action:

coronoid process and medial epicondyle of humerus

middle convexity of lateral surface of radius
pronates and flexes forearm (at elbow)

Palpation of the Thenar Eminence

Patient position: supine or seated
Practitioner position: standing at the side of the table, level with the patients pelvis or lower
abdomen and facing toward the patient. If seated, stand to one side, facing the patient
Applicator:
pad of the finger, thumb
Procedure:
a. place the patients 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: supine or seated
Practitioner position: standing at the side of the table, level with the patients pelvis or lower
abdomen and facing toward the patient. If seated, stand to one side, facing the patient
Applicator:
pad of the finger, thumb
Procedure:
a. place the patients 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: supine or seated
Practitioner position: standing at the side of the table, level with the patients pelvis or lower
abdomen and facing toward the patient. If seated, stand to one side, facing the patient
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: supine or seated
Practitioner position: standing at the side of the table, level with the patients pelvis or lower
abdomen and facing toward the patient. If seated, stand to one side, facing the patient
pad of the fingers
Applicator:
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: seated or supine
Practitioner position: standing at the side of the table so that you are at the level of the
patients elbow. Standing to the side of the patient facing them
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:
Practitioner:
Applicator:
Procedure:

seated
standing in front of the patient.
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 (5th digit) together.

Passive Range of Motion to the Elbow

Patient:
Practitioner:
Applicator:
Procedure:

seated
standing in front of the patient.
hand, fingers
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 patients wrist or distal forearm
c. to assess elbow flexion, bring the patients 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
patients limb.
e. ask the patient to move their arm by their side and flex their elbow to
90 degrees, or move the patients upper extremity into this position yourself.
f. with your palpating hand, cup the elbow and with your non-palpating
hand hold your patients hand
g. use your hand to turn the patients 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 patients
forearm between the side of your body and your arm (medial aspect facing
the ceiling). Have slight flexion of the patients elbow
j. place your hands on either side of the patients forearm, just distal to the
elbow joint
k. for medial gapping, gently push against the patients proximal radius. For
lateral gapping, gently push against the patients 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:
Practitioner:
Applicator:
Procedure:

seated
standing in front of the patient.
hand, fingers
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 patients hand. You can hold the patients 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 2nd and 5th
metacarpal bones). You can also change your hand hold to more efficiently
move the patients 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:
Practitioner:
Applicator:
Procedure:

seated
standing in front of the patient.
hand, fingers
a. place your thumb on the posterior aspect of the 2nd metacarpal bone and
the other thumb on the posterior aspect of the 3rd metacarpal bone. Wrap
your fingers around the hand and let your fingers lie approximately under the
2nd and 3rd 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 3rd to 5th metacarpal bones.
d. hold the patients hand with one hand to stabilize it
e. with the other hand place a finger on either side of the patients 2nd
proximal phalanx and bring the phalanx toward the palm of the patients hand
to assess flexion at the metacarpophalangeal joint. Move the phalanx away
from the patients 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 patients 2nd 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 patients 2nd 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 patients thumb on either side.
l. move the thumb away from the hand in an palmar abduction/adduction,
abduction/adduction and circumduction motion at the 1st carpometacarpal
joint. (One motion at a time.)
m. introduce flexion and extension at the metacarpophalangeal joint, and
interphalangeal joint of the thumb