Documentation of Examination
This may be used as a template or example of what you may want to include in the documentation of your hand and wrist exam. You may also use this PDF version of the documentation for printing.
Inspection:
Documentation of (absence/presence) of ecchymosis, swelling, deformity or defect or atrophy.
Range of motion of the wrist:
Flexion to (xx degrees or full). Extension to (xx degrees or full). Radial deviation (xx degrees or full). Ulnar deviation (xx degrees or full).
Range of motion of the fingers:
Flexion and extension (xx degrees or full) for each of the fingers at the distal interphalangeal joint, proximal interphalangeal joint and metacarpal phalangeal joint. Finger abduction and adduction and thumb opposition.
Palpation:
(Tenderness/no tenderness) to palpation of (specific areas or landmarks such as radial styloid, lister's tubercle, anatomic snuff box, scapholunate junction, ulna styloid, triangular fibrocartilage complex, pisiform, hamate, scaphoid tubercle, metacarpals and phalanges).
Specific Testing:
(Positive/Negative) Carpal Compression Test, (Positive/Negative) Phalen's Test, (Positive/Negative) Tinel's test over the carpal tunnel
(Positive/Negative) Ulnar Compression Test, (Positive/Negative) Frommet's sign, (Positive/Negative) Tinel's test over the ulnar tunnel
(Positive/Negative) OK sign (Positive/Negative) Watson's test, (Positive/Negative) Shuck test (Positive/Negative) anatomic snuffbox tenderness (Positive/Negative) Finkelstein's test, (Positive/Negative) Axial grind test of thumb, (Positive/Negative) tenderness or laxity of the Ulnar collateral ligament of thumb
(Tenderness/no tenderness) DIP, PIP or MCP or shafts of phalanges. (Laxity/no laxity) of the ulnar and radial collateral ligaments of the phalanges (Positive/Negative) Boyes' Test, (Positive/Negative) Elson's Test
Neurovascular Exam:
Document resisted wrist extension (radial nerve), opposition of thumb (median nerve), digit abduction (ulnar nerve). Radial and ulnar pulses. Capillary refill. Sensory exam.