The Hand and Wrist Examination for Video Telehealth Encounters

Introduction

The coronavirus-induced worldwide pandemic has caused adaptations in nearly every aspect of life. In health care, in particular, telehealth visits are one facet that has seen a tremendous transformation over this difficult time. Clinicians have responded to the challenge of coronavirus by fighting to create safe environments for patients and to preserve as much physical distance as possible [5,11,23]. Telehealth visits are one of the tools clinicians are using to fight this virus. For perspective, at a single, large, metropolitan, academic institution, telemedicine visits increased 135% from March 2, 2020, to April 14, 2020, in the urgent care setting, and 4345% in the non-urgent care setting [22]. In 2016, less than 12% of family medicine practitioners and pediatricians worked in an environment with telehealth access [12]. By June 2020, roughly 2 months after the start of the pandemic, less than 10% of primary care physicians worked in environments that did not offer telemedicine access [28]. As clinicians continue to utilize telemedicine with increased frequency, it is imperative that the essential aspects of patient care be preserved throughout these encounters.

One of these crucial aspects of patient care is patient satisfaction. In a cross-sectional survey of over 1500 patients, more than 94% of patients reported to being “very satisfied” with all telehealth attributes during their encounters [27]. In a noninferiority randomized clinical trial, there was no significant difference seen between in-person and telemedicine encounters with respect to physician’s patient-centered communication [1]. There was no difference found between in-person and telemedicine encounters with respect to patient satisfaction with physician’s clinical competence or interpersonal skills. Patients did, however, report greater satisfaction with convenience of telemedicine compared to in-person encounters [1].

While telehealth visits are well received by patients, orthopedic telehealth visits, and visits of the hand and wrist specifically, present a unique set of challenges. One of the central properties of the hand and wrist exam is the sensory examination. Tactile sensation, two-point discrimination tests, and nerve distribution patterns can be particularly challenging when examining a patient remotely [10]. Other aspects of the exam are more easily replicated in the telehealth setting. Studies have shown that roughly 94% of patients are able to take an adequate photograph of their surgical site after carpal tunnel release [35] and that roughly 88% of patients are able to record sufficient range of motion and motor exam when compared to an in-person physical exam recorded on the same day [4]. These studies offer optimistic insight and suggest that excellent care may be preserved with increased telemedicine utilization.

The purpose of this article is to provide a thorough description of the physical examination of the hand and wrist for telemedicine clinical visits. This will include (1) a complete checklist with documentation for all portions of the history and physical exam; (2) appropriate explanations of any physical exam maneuver that may be asked of any patient; and (3) clear, verbal instructions to patients in lay terms to avoid confusion.

Overview of Virtual Hand and Wrist Examination

The hand and wrist examination will be broken down into several sections. The first section will be a generalizable, non-specific overview of the hand and wrist examination, including motor and sensory testing, inspection, palpation, range of motion testing, and a vascular assessment [6,33]. The next group of sections, each of which is accompanied by topic-specific checklists, will feature more detailed, specialized tests for eliciting responses in certain domains [14]. These include inspection of the extremity of interest and a detailed vascular exam with instructions on how to use any accessory instruments when applicable. Instructions are included on how to instruct an adequate sensory exam with household tools when necessary. A detailed motor examination of the upper extremity assessing both the intrinsic and the extrinsic muscles of the hand and wrist, with assessment for any accompanying mechanical dysfunction, is outlined next. Finally, guidelines for completing an assessment of motion are also included.

Comprehensive Virtual Hand and Wrist Examination

The comprehensive exam of the hand and wrist begins with the same steps as an in-person exam, leading with inspection and palpation (Supplemental Table 1). The patient should be positioned so that the clinician can easily view the patient’s hands and wrists, resting comfortably on an even surface when possible [36]. Observing the position of the hands and wrists at rest may demonstrate certain pathology, including but not limited to neurologic palsies [3,19]. The limb should be evaluated for trauma by noting any ecchymosis, abnormal swelling, or lacerations. If a patient endorses pain in an area near the metacarpal, they should be encouraged to “make a fist” with the affected hand. If the injured finger overlaps or “scissors” an adjacent finger, this may be indicative of a metacarpal fracture with an associated rotational deformity [17]. In the event that a patient presents with an open injury, the wound should be inspected for the presence of purulent drainage or foreign material. The entire distal upper extremity should be inspected, including the nail complex. Proper inspection may help identify brittle nail plates, spots, or pitting, which can be indicative of underlying nutritional abnormalities, or chronic disease [14]. Inspection of post-surgical wounds may be performed during this time, and clinicians should attempt to ensure that a high-resolution camera is available for both the patient and the provider.

Palpation is performed using the opposite hand to assess for tender areas, swelling, or asymmetrical masses. If a patient presents with a specific chief complaint of pain or discomfort, they may be encouraged to identify the affected area by “pointing with one finger” to the specific location. Relevant history should accompany any significant exam findings. If a patient identifies a mass, they should be asked about whether it is tender, and encouraged to assess its mobility.

The motor exam is then performed by encouraging the patient to flex and extend all digits and bilateral wrists, with care taken to observe for any abnormalities during motion, including locking or catching, or deficits with respect to range of motion [7,21]. Wrist flexion and extension are used to assess the strength of the wrist flexors and extensors and to assess the motor function of the median and radial nerves, respectively. The volar and dorsal interossei muscles are assessed by encouraging patients to adduct and abduct their fingers. This is also an assessment of the integrity of the motor branch of the ulnar nerve. The anterior interosseous nerve may be assessed by encouraging the patient to make an “OK” sign with their thumb and index finger, thereby flexing the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger [16]. The posterior interosseous nerve may be assessed by encouraging the patient to give a “Thumbs Up” with resisted thumb extension [20].

Sensation is assessed with a goal of initially assessing sensation to light touch. The patient will be instructed to take a soft object and gently place it along the palm of the hand and each digit. Particular care should be taken to ensure that sensation along the volar aspect of the pinky finger is assessed to evaluate ulnar nerve sensation, the volar aspect of the index finger is assessed to evaluate median nerve sensation, and that the first dorsal web space is assessed to evaluate superficial radial nerve sensation. Two-point discrimination may also be evaluated with reliable assessments performed with the aid of a paper clip and a piece of measuring tape [9].

Special Testing

Specialized testing in the hand and wrist most commonly involves testing for ligamentous injury or testing the integrity of motor branches of peripheral nerves (Supplemental Tables 2 and 3). The following sections describe techniques to perform specialized testing in the virtual setting.

Ligament testing

A common chief complaint is thumb pain, especially after trauma. A patient may report a common story of experiencing ulnar-sided thumb pain after a skiing injury. If there is concern for a “skier’s thumb” or an ulnar collateral ligament tear of the metacarpophalangeal (MCP) joint of the thumb, the patient may stress the MCP joint of their thumb. This should be performed by radially deviating the thumb from the MCP joint both in full flexion and full extension [30]. While carefully observing the full arc of motion, the clinician should attempt to observe for greater than 30 degrees of motion in both positions. If patient comfort allows, the non-injured thumb may also be tested for comparison [30].

Ligamentous instability can also be found in the carpal bones of the wrist. Scapholunate ligament tears may be identified with the scaphoid shift test, or Watson’s test [18]. It is performed by placing the opposing thumb on the volar aspect of the distal pole of the scaphoid. Patients may be encouraged to take their opposite thumb and place pressure against “the top of the bone at the bottom of the palm.” This should be done under direct visualization so that a provider can ensure that the hand is placed appropriately. The patient should then be encouraged to ulnarly and radially deviate their wrist while holding constant pressure over the scaphoid as the clinician demonstrates this movement. A palpable clunk may be appreciated by the patient.

The triangular fibrocartilage complex (TFCC) is a common source of pathology for patients and may be evaluated virtually. The piano key test may be performed by a patient and allows for visual confirmation of pathology. The patient is encouraged to place both hands on a table with the palms facing down. They are then encouraged to forcefully press their palms on the table. If the distal ulna is notably prominent, this may be indicative of TFCC injury or distal radioulnar joint (DRUJ) pathology [2,24].

Motor nerve testing

Motor nerve deficits of the hand and wrist represent some of the most common pathologies in the upper extremity and present in various ways. Carpal tunnel syndrome may be evaluated in the telehealth setting in many ways. Providers may instruct patients to gently tap on the base of the palm over the distal palmar crease, performing Tinel’s test, and ask whether this produces paresthesias in the median nerve distribution [34]. Providers may also elect to perform Phalen’s test, where they instruct patients to place their palms against one another and allow their wrist to flex by gravity. This flexion is permitted for up to 2 minutes, where patients may again report symptoms within a median nerve distribution [32].

The motor branch of the ulnar nerve also frequently presents with pathology. Patients may be instructed to hold a piece of paper between their thumb and index finger on the affected side. They should then attempt to pull the piece of paper away with the opposing hand while the affected side resists. If the patient flexes the interphalangeal joint of their thumb, this represents a positive finding of weakness of the motor branch of the ulnar nerve [31]. Patients may also be asked to hold all of their fingers in adduction with their fingers fully extended while the provider demonstrates the position. If the small finger drifts into abduction, this is also indicative of a deficit of the motor branch of the ulnar nerve, indicating a positive Wartenberg’s sign [15].

Limitations

There is no substitute for an in-person physical exam with a trained clinician. Subtle findings on physical exam may be difficult for the patient to appreciate and may not be observed by the provider on video. Even with that understanding, 98% of physicians rate their ability to examine patients through video-assisted orthopedic telemedicine encounters as good or very good [10]. While many of the aforementioned maneuvers may be performed unassisted in a virtual setting, many limitations remain. At the wrist, a patient presenting with a chief complaint concerning for DRUJ instability may benefit from evaluation by performing a shuck test [26]. This test must be performed with two hands and may require experience that most patients lack in order to appreciate a subtle difference when compared to the contralateral side. Patients who present with trauma may endorse tenderness at the base of the thumb. In particular, anatomic snuff box tenderness can cause concern for a possible scaphoid fracture, a devastating injury with a potentially prolonged treatment course [13]. The subtlety of the physical exam along with the urgency to obtain radiographs necessitates that this injury be evaluated in-person.

Acute tendon lacerations are another common trauma. The treatment protocol depends on the degree of injury to the tendon, the presence of foreign material, and the manner in which the injury occurred (which may include dirty objects, animal bites, or even human bites) [8,25,29]. Patients who present with concern for open tendon lacerations should be evaluated in-person.

The telemedicine setting can be an excellent way to perform a basic, comprehensive physical exam of the upper extremity in patients without known life- or limb-threatening injuries. Significant findings also often benefit from additional imaging. Providers should understand the limitations of the virtual visit, and it is our recommendation that if a patient has is any concerns that are unable to be properly evaluated in a telemedicine setting, they should be scheduled for an in-person visit.

Conclusion

A worldwide pandemic has brought about changes throughout medicine, not the least of which is the increased use of telemedicine as first-line care in orthopedic surgery [37]. Providers are confident in their ability to provide excellent care and patients report high satisfaction after telemedicine visits [1,10]. Clinicians are able to perform an exam of the hand and wrist which evaluates the motor function, sensory integrity, basic inspection and palpation, and certain specialized provocative maneuvers. The techniques and verbal cues outlined here provide a framework for completion of a comprehensive physical exam of the distal upper extremity. This does not, however, replace all of the elements of an in-person exam and clinicians should not hesitate to encourage patients to come in for an in-person exam if they feel that an essential aspect of the exam may not be ascertained virtually.