Evaluation of the Hand and Wrist via Telephone and Video Visit

Abstract

Background: The COVID-19 pandemic has highlighted the utility of telemedicine, with rapid incorporation throughout 2020. Telemedicine is a timely, safe, and effective means of evaluating, triaging, and treating patient conditions, including those of the musculoskeletal system. Hand and wrist complaints are frequently encountered in the primary care setting, and some can have serious consequences if not promptly diagnosed. Prior to the pandemic, over a quarter of the nation's allopathic degree-granting medical schools had initiated telemedicine training as part of the preclinical phase of their curriculum, and about half had implemented it into clerkships prior to the pandemic. Despite rapid acceptance, increased ease of access, and prior attempts to incorporate telemedicine into the educational curriculum, telemedicine evaluation continues to pose challenges to both the patient and provider. This is likely due to a lack of established protocols outlining clinical data collection through a virtual interface. Although telemedicine requires the patient to perform a physical examination, it allows the physician to collect clinically important information while observing the patient in their home environment.

Aims: The aim of this paper is to provide a step-by-step method to evaluate and triage hand and wrist complaints.

Methods: Our group has created a step-by-step evaluation pathway to help physicians direct their patients through typical hand and wrist examination elements, including inspection, palpation, range of motion (ROM), strength, special, and functional testing.

Results: We have developed a table of evaluation questions and instructions and a glossary of images of each maneuver to facilitate hand and wrist examination via telemedicine.

Conclusion: This paper provides a guide for extracting clinically relevant information while performing telemedicine examinations of the hand.

Keywords: access to health care; hand and wrist pain; hand evaluation; tele health; wrist evaluation.

Figure 1. Anterior and posterior view of hand and wrist

(A) Anterior view of the proximal row of carpal bones (curved line) and (B) distal row of carpal bones (bracket).

Figure 2. Observation for ganglion cyst

A possible pathology of the dorsal wrist is a ganglion cyst; the possible location is demarcated by the star.

Figure 3. Anatomic alignment of the metacarpal bones

(A) Normal anterior anatomic alignment, the digits point toward the base of the thumb. With a potential fracture or injury, the metacarpal or phalange could deviate from the normal alignment. (B) Normal posterior alignment of the metacarpal heads forms a smooth arc (curved line). If this is disrupted, a possible metacarpal fracture may be present.

Figure 4. Ulnar claw

This sign is suggestive of pathology of the ulnar nerve.

Figure 5. First carpometacarpal joint

(A) Location of the first carpometacarpal joint; (B) if the patient appreciates squaring of the first carpal metacarpal joint it could be suggestive of osteophyte formation and osteoarthritis.

Figure 6. Finkelstein test

(A) Lateral view of the Finkelstein test, pain along the first dorsal compartment of the wrist (star) is support of De Quervain tenosynovitis. (B) Superior view of the Finkelstein test, this position can be used to instruct the patient to palpate the anatomic snuff box (bracket).

Figure 7. Guyon canal

The Guyon canal is indicated by the finger point. Reproduction of symptoms at this area with palpation could indicate ulnar nerve entrapment, ulnar artery compromised or (hammer syndrome) or fracture of the hook of the hamate.

Figure 8. Tinel's sign

Percussion at the transverse carpal ligament (star) that reproduces radicular symptoms into the hand suggest median nerve involvement.

Figure 9. Phalen and reverse Phalen tests

(A) Phalen test; (B) reverse Phalen test. These tests are positive when they reproduce radicular symptoms in the median nerve distribution in the hand.

Figure 10. Valgus stress test of the thumb

Valgus stress test of the ulnar collateral ligament of the thumb can be performed by instructing the patient to gap the first carpal metacarpal joint (arrow indicates the motion vector). A positive test is an increase in joint gapping and pain reproduction.

Figure 11. Differential diagnosis flow chart

Abbreviations for Important Anatomical Structures of the Hand and Wrist. CMC: carpometacarpal; ECU: extensor carpi ulnaris; FCU: flexor carpi ulnaris; STT: scaphotrapeziotrapezoid; TFCC: triangular fibrocartilage complex; UCL: ulnar collateral ligament.