Pediatric Orthopaedic Exams: The Hand and Wrist

Robert B. Carrigan, MD, hand and upper extremity surgeon at Children's Hospital of Philadelphia (CHOP), demonstrates how to properly perform a hand and wrist exam on a pediatric patient, including assessment for congenital anomaly, joint contractures, disruption of the flexor or extensor tendons, scaphoid fractures, carpal instability, ulnar-sided injury, and more.


Pediatric Orthopaedic Exams: The Hand and Wrist

Robert B. Carrigan, MD: Good afternoon. My name is Robert Carrigan. I’m an Orthopedic Surgeon whose practice specializes in hand and upper extremity conditions in children ages infants to adolescence. And Stewart, good day, how are you? I’m just going to take a moment for some hand hygiene and head over here to the hand sanitizer and wash my hands. And good afternoon to you. Thank you for coming to see us. Are you doing well today? 

Stewart, patient: Yeah. 

Dr. Carrigan: Great. So Stewart is here for an examination of his hand, and we’re going to begin with the basics of the hand examination, and with that really begins with a simple inspection. 

So, I’m inspecting Stewart’s hand to see that he has a thumb and four fingers. Now, that may seem rather obvious in most people’s cases that they have a thumb and four fingers, but some kids are born with more that the requisite number of digits, and that’s called polydactyly. And some people are born with absent thumbs or missing digits. So I see that Stewart’s thumb is of normal size, it’s of appropriate length. The web spaces, or the spaces between the digits, are of normal length. They don’t go too far past the knuckles, and you don’t have any webbing in that area. We see that Stewart has nails on all his digits, and they’re normally sized and appropriately shaped. We also notice that Stewart’s hand is very supple, meaning that he has normal passive range of motion. 

Stewart, you can go ahead and make a tight fist for me and straighten those fingers out. There are no joint contractures that we see. And we also see that the muscle tone within Stewart’s hand is normal. There’s no increased spasticity that we see. So that’s really begins with significance just for his general inspection of his hand. 

We also note that his hand is warm and well-perfused, meaning that he has good vascular flow through his finger tips and there’s no concern for vascular insufficiency. So sometimes kids will see me for injury, and I’m concerned about the disruption of the flexor tendons or the extensor tendons. So I will isolate ... so for instance, so if Stewart, we had a concern you had cut yourself along your middle finger and you had a disruption of the flexor tendons, I’ll ask you simply to bend the tip of your finger down here along the middle finger. And we can see that his flexor digitorum profundus is functioning normally, and that similarly here we’ll isolate the superficialis tendon, and that’s functioning normally as well, so he’s got no disruption of that. 

We’ll go to the dorsum of his hand, and we’ll ask Stewart to straighten your fingers out for me fully. So straighten your fingers out on this hand here, straighten it all out. I’m going to push against you, and you get some resistance. And he’s doing good. He can straighten all his fingers out, and the mechanisms are working normally. 

So we also may have concern for a more traumatic injury such as a broken bone. And one of the bones we see in the wrist that is commonly broken and missed is the scaphoid bone, which a peanut-shaped bone here on the radial aspect of the wrist. So to isolate that, we’ll often deviate the wrist ulnarly and we’ll palpate here on the waist of the scaphoid and ask Stewart if he has any pain, which he does not appear to have any. So we have no concern for a scaphoid fracture this way. 

So, if Stewart has some concern for what we call “carpal instability,” or instability of his wrist, we make a performance called Watson’s Maneuver, which is really an examination of his carpal bones, where I take the thumb, my thumb, and place it here on the distal pole of his scaphoid. I translocate his wrist, putting palmar pressure volarly across his wrist. And I move his wrist from an ulnar to a radial fashion to see if I can appreciate any clicking, or clunking, or pain. We don’t appreciate any of that on Stewart today, and it looks like he’s got a good functioning wrist. 

Similarly, if he has some concern for an ulnar-sided injury, or injury toward the small finger, we will palpate here ulnarly in this little cartilaginous region called the triangular fibrocartilage complex, and we’ll ask him if he has any pain. And Stewart clearly does not have any discomfort in that area, so we have no concern. 

We’ll isolate his distal radial ulnar joint here, and we’ll put some translocation pressure across this area causing a ... it’s called a piano key test. We’ll see if there’s any discomfort or increased translation. We do that in full pronation, neutral. As well as full supination, and he’s stable throughout those arcs of motion, so there’s no concerns for that. 

So, Stewart I can tell you this, that based upon your examination today, you have a good right upper extremity, a good hand, and I don’t think you’re going to have any problems. What do you think about that? 

Stewart: Good.

Dr. Carrigan: All right. Dynamite. OK. All right.

Related Centers and Programs: Division of Orthopaedics, Hand and Arm Disorders Program