• Follows the IP-PASS examination methodology
  • Inspection
  • Palpation
  • Passive Range of Motion
  • Active Range of Motion
  • Strength & Neurovascular
  • Special Tests

Inspection

• Skin
  • Color: erythema, ecchymosis, pallor, black
  • Trophic changes (altered hair growth, sweat production)
  • Scars
• Swelling
• Muscle tone
  • Thenar atrophy: Median Nerve injury
  • Interosseus atrophy: Ulnar Nerve Injury
• Deformity
  • Asymmetry
  • Radial or ulnar deviation
  • Rotation
  • Amputation
  • Athritic nodes
  • Butonniere
  • Swan Neck
• Angulation: Cascade Sign

Palpation

• Joint Effusion
• Clicking
• Snapping
• Crepitus
• Tenderness
• Temperature
• Masses

Range of Motion

• Finger
  • MCP: 0° – 85°
  • PIP: 0° – 110°
  • DIP: 0° – 65°
• Wrist
  • Flexion: 60°
  • Extension: 60°
  • Radioulnar Deviation: 50°

Strength and Neurovascular

• Sensation
  • Recommend: 2 point discrimination (use paper clip)
  • Light touch
• Motor:
  • Median Nerve: “A-OK” sign: flexion of thumb and index finger or thumb and pinky against resistance
  • Ulnar Nerve: Test fingers against resistance in abduction
  • Radial Nerve: Test thumb extension against resistance
• Vascular
  • Radial pulse
  • Ulnar pulse
  • Allen’s Test

Special Tests

• De Quervains Tenosynovitis
  • Finkelstein’s Test
  • Eichhoff’s Test
• Central Slip Extensor Tendon Injury
  • Elson’s Test
• Gamekeeper’s Thumb
  • UCL Stress Test (Thumb)
• TFCC Injury
  • TFCC Shear Test
  • TFCC Stress Test
• Wartenbergs Syndrome
  • Tinel’s Test
  • Finkelstein’s Test
• Carpal Tunnel Syndrome
  • Tinels Test
  • Phalens Test
  • Durkan’s Test
• Scapholunate Instability
  • Scaphoid Shift Test
• Lunotriquetral Instability
  • Reagans Test
  • Kleinman’s Shear Test
• Distal Radial Ulnar Joint Instability
  • Piano Key Test
• Carpometacarpal Arthritis
  • Thumb CMC Grind Test

• Special tests
  • Palpation
    • grind test
      • used to test for pathology at the thumb carpometacarpal joint (CMC)

      • examiners apply axial load to the first metacarpal and rotate or “grinds” it

      • positive findings: pain, crepitus, instability

    • Finkelstein’s 
      • used to test for DeQuervain’s tenosynovitis

      • the patient makes a fist with fingers overlying the thumb

      • examiner gently ulnar deviates the wrist

      • positive findings: pain along with the 1st compartment

  • Range of motion
    • flexor profundus 
      • used to test the continuity of FDP tendons

      • MCP + PIP joints were held in extension while the patient asked to flex FDP, thereby isolating FDP (from FDS) as the only tendon capable of flexing the finger

    • flexor sublimus 
      • used to test for continuity of FDS tendon

      • MCP, PIP, and DIP of all fingers held in extension with hand flat and palm up; the finger to be tested is then allowed to flex at PIP joint.

    • Bunnel’s test
      • examiner passively flexes PIPJ twice
        • first with MCP in extension

        • next MCP held an inflection

      • intrinsic tightness present if PIP can be flexed easily when MCP is flexed but NOT when MCP is extended

      • extrinsic tightness present if PIP can be flexed easily when MCP is extended but NOT when MCP is flexed

  • Stability assessment
    • scaphoid shift test (Watson’s test) 
      • tests for a scapholunate ligament tear

      • examiner places a thumb on the distal pole of the scaphoid on the palmar side of the wrist and applies constant pressure as the wrist is radially and ulnarly deviated

      • dorsal wrist pain or “clunk” may indicate instability

    • lunotriquetral ballottement 
      • tests for a lunotriquetral ligament tear

      • examiner secures the pisotriquetral unit with the thumb and index finger of one hand and the lunate with the other hand

      • anterior and posterior stresses are placed on the LT joint

      • positive findings are increased laxity and accompanying pain

    • midcarpal instability
      • examiner stabilizes distal radius and ulna with the non-dominant hand and moves patients wrist from radial deviation to ulnar deviation, whilst applying an axial load

      • a positive test occurs when a clunk is felt when the wrist ulnar deviates

    • ulnar carpal abutement
      • tests for TFCC tear or ulnar-carpal impingement

      • examiner ulnarly deviates wrist with axial compression

      • positive if the test reproduces pain or a ‘pop’ or ‘click’ is heard

    • Gamekeeper’s 
      • tests for ulnar collateral ligament tear at MCP of thumb

      • examiner stresses first MCPJ into radial deviation with MCPJ is fully flexed and extended positions

      • positive test if > 30 degrees of laxity in both positions (or gross laxity compared to another side)

  • Nerve assessment
    • Tinel’s 
      • tests for carpal tunnel syndrome

      • examiner percusses with two fingers over the distal palmar crease in the midline

      • positive if the patient reports paresthesias in median nerve distribution

    • Phalen’s 
      • tests for carpal tunnel syndrome

      • with the hands pointed up, the patient’s wrist is allowed to flex by gravity in palmar flexion for 2 minutes maximum

      • positive if the patient reports paresthesias in median nerve distribution

    • Froment’s sign
      • tests for ulnar nerve motor weakness

      • the patient asked to hold a piece of paper between the thumb and radial side of the index

      • positive if as the paper is pulled away by the examiner the patient flexes the thumb IP joint in an attempt to hold on to paper 

    • Wartenberg’s sign 
      • tests ulnar nerve motor weakness

      • a patient asked to hold fingers fully adducted with MCP, PIP, and DIP joints fully extended

      • positive if a small finger drifts away from others into abduction

    • Jeanne’s sign 
      • tests for ulnar nerve motor weakness

      • ask patient to demonstrate key pinch

      • positive finding if patient’s first MCP joint is hyperextended