Alya Putri Khairani /

130110110220 / C2

Normal X-ray of Forearm and Hand

Standard and new imaging techniques are available and necessary for the diagnosis and treatment
of hand and wrist pathology. Plain x-rays are still the imaging technique of fi rst choice for
assessment of abnormalities of wrist and hand. Magnetic resonance imaging (MRI) and computed
tomography (CT) may be indicated depending on the clinical fi ndings. If a bone injury is suspected,
CT is the better choice. For soft tissue disorders, MRI is indicated, except for intrinsic ligaments
and cartilage, for which arthrogram followed by CT (arthro-CT) is the most sensitive tool
The radioanatomy of the elbow is studied via an AP X-Ray image and one in profile, showing the medial and lateral
Epicondyles, the Olecranon, the head and neck of the Radios, the radial and Olecranon Fossae, the Humeral
Trochlea and allow of the anatomical structures composing the Humeroulnar joint, Humeroradial joint and proximal
Radioulnar joint

Elbow
A-P
View

Frontal and side views of the forearm show the radiological bony structures of the Radius and Ulna

Alya Putri Khairani /

130110110220 / C2

Plain frontal and side-view X-Rays of the wrist show the lower extremities of the Radius and Ulna, the Radiocarpal
joint, the Carpal bones (Scaphoid, Capitate, Trapezium, Trapezoid, Hamate, Lunate, Pisiform and Triquetral) and the
Carpometacarpal joints

Alya Putri Khairani /

130110110220 / C2
2 X-Ray images of the hand (AP and oblique views) show the Carpal bones, the bones of the hand (Metacarpals)
and fingers (Phalanges)

Alya Putri Khairani /

130110110220 / C2

Page Interpretation
Carrying Angle
When your arms are held out at the sides and your palms are facing forward,
your forearm and hands should normally be about 5 to 15 degrees away from
the body. This is the normal "carrying angle" of the elbow. This angle allows
your forearms to clear the hips when swinging your arms, such as during
walking. It is also important when carrying objects. Certain fractures of the
elbow can increase the carrying angle of elbow, causing the arms to stick out
too much from the body. This is called an excessive carrying angle, Cubitus
Valgus. Example: complication of fracture of the Lateral Condyle of the
Humerus, which may lead to tardy/delayed Ulnar Nerve Palsy. Doctors use a
measuring device called a Goniometer, which looks similar to the hands of a
clock, to measure a patient's carrying angle and assess for elbow damage

Thomsen Test

This test is usually being used to indicate Lateral Epicondylitis. The patient is
requested to make a fist and extend the elbow with the hand in slight
dorsiflexion. The examiner immobilizes the dorsal wrist with one hand and
grasps the fist with the other hand. The patient is then requested to further
extend the fist against the examiners resistance, or the examiner attempts to
press the dorsiflexed fist into flexion against the patients resistance

Range of Motion of Elbow

Motoric Muscle Tone

Muscle tone (residual muscle tension or tonus) is the continuous and passive partial contraction of the
muscles, or the muscles resistance to passive stretch during resting state. Part of the Neurological examination.
Quantify with 0 5 Scale (quasi-objective)

Alya Putri Khairani /

130110110220 / C2

0/5 - No movement

1/5 - Barest flicker movement not enough to move structure to which attached.

2/5 - Voluntary movement not sufficient to overcome force of gravity. E.g. patient able to slide hand across
table - but not lift it from surface

3/5-Voluntary movement capable of overcoming gravity, not any applied resistance.E.g. patient raises hand
off table, but not w/any additional resistance applied

4/5-Voluntary movement capable of overcoming some resistance

5/5 -Normal strength

+ and can be added to allow for more nuanced scoring

Range of Motion of Hand and Wrist

Hand Dexterity
Dexterous hand skills are known as Fine Motor Skills. Fine motor skills are essential for performing everyday skills
like cutting, self care tastks (such as managing clothing fastening, opening lunch boxes, cleaning teeth) and pencil
skills.
Tinels Sign
Tinel's sign is a physical exam finding that can help point
to the diagnosis of carpal tunnel syndrome. If its
positive, it indicates a median nerve lesion. The patients
hand is slightly dorsiflexed; the dorsum of the wrist rests
on a cushion on the examining table. The examiner taps
the median nerve at the level of the wrist crease with a
reflex hammer or the index finger. Paresthesia and pain
radiating into the hand and occasionally into the forearm
as well are signs of a compression neuropathy of the
median nerve. The test will produce a false negative
in a chronic
compressionofneuropathy
in nerve,
which
The pathophysiology of Tinels sign is thought to involve result
abnormal
mechanosensitivity
the involved
presumably due to the disease process. This results in afferent discharge at the level of the regenerating nerves,
thus producing a pins and needles sensation, which characterizes the sign. On a cellular level, the sign may be
caused by an abnormally excitable membrane

Alya Putri Khairani /

130110110220 / C2
Phalens Test
Phalen's test, or wrist flexion, checks for pain, tingling, or numbness that may suggest carpal tunnel problems. The
pathophysiology of Phalens maneuver involves two aspects. First, patients with carpal tunnel syndrome have
increased pressure in the carpal tunnel at rest, which is exacerbated by the flexion of the wrist. Second, the nerve
fibers in the median nerve are pathologically abnormal, which results from the disease process and contributes to
the paresthesia when the nerve is compressed between the transverse carpal ligament and the flexor
tendons. The wrist flexion sign is evaluated by having the patient drop his or her
hands into palmar flexion and then maintain this position for about ten minutes.
Pressing the dorsa of the hands together increases pressure in the carpal tunnel.

Prayers Test (Reverse Phalen Test)

Indicates carpal tunnel syndrome. The seated patient is asked to
press both hands together in maximum dorsiflexion and to
maintain this position for one minute. This position increases the
pressure in the carpal tunnel. Paresthesia in the region supplied
by the median nerve is a sign of carpal tunnel syndrome. The
reverse Phalen test is less reliable than the Phalen test.

*Electrodiagnostic Examination
In an attempt to determine if the diagnosis of carpal tunnel syndrome can be made clinically or should be
confirmed electrodiagnostically, the physical signs have been compared with nerve conduction studies. In one
study, 64% of 88 hands of patients with a positive Phalens test had positive results on electromyography (EMG),
whereas 51% of 78 hands of patients with a negative Phalens test had positive results on EMG.16 Likewise, 60% of
68 hands of patients with a positive Tinels sign had positive EMG studies, whereas 55% of 104 hands of patients
without a Tinels sign had positive EMG studies