REIDER PART 1
35

Chaptfr 4_Hand and Wrist 125

4-1 • When a patient complains of pain on the radiaI side of the wrist

If There is a History of Trauma:

Wrist swelling and pain:

•    Distal radius fracture

•    Scaphoid fracture

•    Bennett's or Rolando's fracture (base of first metacarpal)

•    Scapholunate ligament injury

If There is No History of Trauma:

Wrist pain with or without swelling:

•    DeQuarvain's (first dorsal compartment) tenosynovitis

•    Radioscaphoid arthritis (SLAC wrist)

•    Basilar joint instability

•    Basilar joint arthritis

Relevant Physical Exam:

General:

•    Look for swelling

•    Palpate for synovitis

•    Feel for crepitus

Fractures:

Distal radius fracture:

•    Tenderness with or without deformity over the radius. Pain in the wrist joint indicates an intraartic-ular fracture with bleeding.

Scaphoid fracture:

•    Tenderness in the anatomie snuff box

•    First metacarpal fracture: pain and deformity at the base of the thumb

Scapholunate ugament injury:

•    Tenderness over the scapholunate ligament

•    Abnormal scaphoid shift test (Watson's test) DeQuervain's tenosynovitis

•    Abnormal Finkelstein test

•    Tenderness over the first dorsal compartment

Radioscaphoid arthritis:

•    Synovitis over the radial styloid

•    Tenderness of the radioscaphoid joint

•    Limited rangę of motion of the wrist Basilar joint arthritis:

•    Abnormal grind test

•    Abnormal shuck test (morę severe cases)

•    Loss of abduction of the thumb

•    Hyperextension of the MP joint of the thumb when grasping objects

Basilar joint instabiuty:

•    Negative grind test

•    Pain with pinching

•    Dorsal and/or radial subluxation with pain that is eliminated with lidocaine injection

ring of the cxtensor tendons with secondary contracture of the capsule of the involved interphalangeal joint or contracture of the intrinsic muscles resulting in excessive ten-sion on the finger extensor tendons. The Bunnell-Littler test for intrinsic tightness can be used to differentiate between these two possibilities. To perform this test, the

examiner stabilizes the MCP joint of an individual finger in the extended position and attempts to passively flex the finger (Fig. 4-39z\). The amount of finger flexion is noted. The examiner then passively flexes the MCP joint and again assesses the passive flexion of the finger. If passive interphalangeal joint flexion inereases with flexion of the MCP joint, this is evidence for tightness of the intrinsic muscles because flexion of the MCP joint relaxes the intrinsics (Fig. 4-39B). If, on the other hand, passive flex-ion of the MCP joint does not inerease the limited flexion of the involved interphalangeal joint, the limitation is pri-marily a result of a contracture or deformity within the interphalangeal joint itself (Fig. 4-39C). Extrinsic contracture of the long finger extensors can also limit interphalangeal joint flexion through a tenodesis effect. In this case, passively flexing the MCP joint actually produces a decrease in interphalangeal joint flexion because MCP joint flexion further tightens the contracted long finger extensor and thus passively reduces flexion of the interphalangeal joints (Fig. 4-39D).

Abduction and Adduction. The MCP joints are capable of an additional piane of motion not possible in the interphalangeal joints: abduction and adduction. The cam shape of the metacarpal heads allows the collateral liga-ments of the MCP joints to be lax when the joints are extended, thus permitting abduction-adduction. When