Examination of the Hand

Summary

” Do you have RA?”

Look

Patient seated

Hands on pillow

Dorsum

  • Describe proximal to distal
    • Skin
      • Colour, scars, creases
        • distal web skin limit is the midpoint of the proximal phalanx
        • Creases on flexor surface are distal to the joint
        • on the extensor surface they are proximal to the joint
    • Wrist
      • Ganglions, synovitis, prominent ulnar head
    • Hand
      • Swelling
        • Tenosynovitis
        • Carpal bossing: benign bony prominences that form on dorsum of proximal ends of 2-3rd MC
      • Atrophy
        • of intrinsics
          • NB: test peripheral nerves
        • of first interosseus
          • Radial border of 2nd MC
          • Severe ulnar neuropathy
      • MCPJ
        • old Fracture’s, dropped knuckle
        • Carpal bossing (benign prominences at the proximal end of the 2nd/3rd metacarpals)
    • Digits
      • Heberden’s nodes (DIP)
      • Mucous cyst – DIP associated with degenerative changes of joints
      • Bouchard’s nodes – (PIP)
    • Fingernails: deformity, circulation
      • Clubbing (respiratory & cardiac disease)
      • Spoon nails (infection)
      • Fragmentation & pitting (Psoriasis)
      • Ridges (alcohol, vitamin deficiency)
      • Splinter hemorrhages
      • Onychogryposis –thick hook nails
      • Paronychia

Radial surface

Palms together

  • Thenar eminence
  • Z deformity of thumb
  • Dorsum of thumb
    • Arthritis of basilar joint

Volar

Palms Up

  • Creases
    • Distal = proximal limit of the retinaculum
    • Middle = Radio-carpal joint
    • Proximal = proximal limit of synovial flexor sheath
  • Swellings
    • Ganglion
    • Flexor synovitis
  • Fingers
    • Note the general resting posture, there should be increasing flexion from the index to 5th. ? contracture, ? tendon injury (arcade of flexion)
    • Swellings
      • generalized finger swelling vrs localized (joint)
      • Oslers nodes, small tender nodes in the finger pulp, from SBE
      • ganglions (flexor creases)
      • Phelon (pulp infection)
      • Epidermal inclusion cyst
    • Deformities
      • rotational (previous fracture) get patient to flex the fingers, all should point to scaphoid tubercle
      • ulna drift (RA)
      • swan neck
        • follows an untreated mallet or DIPJ dislocation, or occurs
        • primarily in RA
        • After mallet/dislocation, the excessive extensor force causes gradual attenuation of the PIPJ volar plate
        • In RA, the synovitis erodes the volar plate & the hyperextension of the PIPJ cause DIPJ flexion
      • Boutonnière
        • Central slip rupture
          • acute (Trauma) or chronic (RA)
      • claw fingers
        • (loss of intrinsics or over-action of extrinsics)
      • An extrinsic minus hand
        • shown by extending the MCPJ, then able to flex the DIPJ & PIPJ
      • Mallet finger extensor insertion dysfunction (mobile), if fixed may be Osteoarthritis

Then bend elbows to look at ulnar surface

  • elbow – scars or nodules
  • benedectine
  • ulnar clawing
  • Best to see RA features, such as carpal subluxation & Caput ulnae

Feel

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  • Feel – area of interest – go for most pathological finger is multiple regions
  • In general palpate any swellings, scars or prominences & characterize any tender areas
  • Feel for excessive warmth, sweating
  • Proximal to distal, radial to ulnar
  • Name each structure as you go
    • Dorsal
      • radial styloid
      • Anatomical snuff box
      • first dorsal compartment (De Quervain’s)
      • Dorsal branch of radial artery
        • Distal to this is trapezium
      • Ganglion in 2nd dorsal compartment
      • lister’s tubercle
        • SL ligament distal to this
      • DRUJ
      • Ulnar styloid
      • TFC
        • (just distal to ulnar head in a small depression, continue palpating during radial & ulnar deviation, feel a popping), L-T ligament is just distal to the TFC, & extensor tendons (synovitis-RA)
      • Remaining carpal bones & metacarpals
    • Palmer
      • Pulses
      • scaphoid tubercle
      • trapezium
      • Lunate
      • Scapho-trapezium joint
      • Trapezio-metacarpal joint
      • Pisiform & hook of hamate (end of FCU)
      • Palmer fascia
      • thenar & hypothenar eminencies (palpate eminencies whilst the patient presses the tips of the thumb & 5th fingers together)
      • flexor tendons (synovitis)
      • To feel the Palmaris longus
        • press tips of thumb & 5th together, wrist
        • slightly flexed, palpate to the ulnar side of FCR. (Between PL & FCR is median nerve)
      • Fingers & thumbs
        • Palpate swellings & joints

    • Move

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    • Active & if any limited add passive
    • Test passive & active movement, evaluate the end feel
    • Wrist
      • Whilst elbows are bent do
        • Flexion (60-80°)
        • Extension (70-90°)
      • Brings hands down
        • Radial (20°). & ulnar deviation(30-40°)
      • Keep your elbows by yourside
        • Supination
        • Pronation
    • Thumb
      • Lateral abduction
      • Palmar abduction
      • Opposition
      • Extension
      • Retropulsion
      • thumb to LF base
      • thumb to IF(tip to tip,pulp to side)
    • Hand / Fingers
      • Check arcade of flexion
      • Extend fingers
    • Fingers
      • Flexion, extension, abduction (measure span between fingers) & adduction.
      • tendon ruptures
        • EPL post Colles
        • EDC in RA (Vaughan-Jackson lesion)
        • If finger PIPJ flexion limited, perform Bunnel test.
      • Extension
        • Passive MCPJ extension (70-80°) is always > active (0-20°)
        • Can grossly assess flexion by distance of finger tips from the palm
        • Note any triggering
      • Thumb
        • Opposition (distance between fingers)
        • abduction (with reference to the palm)
        • adduction
        • radial abduction = opening up web.
      • Stress
        • Collateral ligaments of the fingers & thumbs
          • IPJ’s in extension or 30°
          • MCPJ’s in 90°

    Functional Assessment / GripsFunctional Assessment / Grips

    >Power Grip – squeeze my fingers
  • Hook Grip – hook my hand
  • Precision Grip hold pen
  • Lateral Pinch Grip – key grip
  • Tip Pinch – pick up coin
  • Function
    • Power grip
      • extrinsic muscles 50% hand function
        • hook (holding bag)
        • cylinder & spherical
    • Precision
      • Intrinsic muscles, 45% hand function
      • pinch grips e.g. holding a key, pen
    • Paper weight
      • Most basic function, 5%, requires limit strength & fine motor
    • Also try doing up a button & tracing a diagram
    • 45% grasp
    • 45% pinch
      • side pinch (key pinch)
      • tip pinch
      • chuck pinch
    • 5% hook
    • 5% paper weight

    • Screening Series

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  • Neck side to side
  • full abduction to over head position
  • touch hands on head – check axilla & elbows for scars
  • behind head
    • flex elbows
    • extend elbows
  • behind lower back
  • then pronation & supination with thumb up & elbows by side
  • then make fist with thumb in & out
  • spread fingers
  • then wrist flexion & extension

    • Special Tests

    Special Tests

    Y EXAMINATION
    Deformities
    • APE HAND
      • Thenar wasting, thumb held in line with fingers (ext tendon pull)
      • Median N palsy
    • BISHOPS HAND
      • Also called benediction hand
      • Hypothenar wasting, intrinsic wasting, partial claw of the ulna side
      • indicates ulnar nerve lesion
    • Ulnar paradox
      • higher the lesion the less the claw
    • CLAW HAND
      • Due to combined median & ulnar nerve palsy
      • All fingers clawed
    • WRIST DROP
      • Radial Nerve lesion
    Motor
    • PosteriorInterosseous
      • ECU, EI, EDC, EPL, EPB, APL (radial thumb abduction)
    • Radial
      • ECRL, ECRB
    • Median
      • FCR, FDP2,3, FDS, FPL, APB (palmer thumb abduction)
      • Opponens (press thumb/5th tips together, check strength & that the thumb is opposing-rotating)
    • Ulnar nerve
      • FCU, FDP4,5, Intrinsics, Adductor policis
    Sensation
    • Median
      • Palmer thumb & 1 • fingers & tips of fingers
      • Palmer cutaneous nerve base of thumb
    • Ulnar
      • Ulnar 1 • fingers
    • Radial
      • Dorsal fingers/hand over median nerve fingers
    Nerve tests

    Froment’s sign

    • Grasp paper between index & thumb of both hands, pull out paper. If the thumb IPJ flexes, then it is an isolated ulnar nerve palsy

    Phalan’s test

    • Hold the wrist flexed for 1 minute. Symptoms of median Nerve indicate CTS

    Tinnels test

    • Tap over the median nerve, pins & needles indicates CTS

    Compression test

    • press for 1 minute on median nerve at the distal palmer crease as it enters the CT, pins & needles is positive

    Ulnar nerve compression test

    • Guyon’s canal beneath the pisio-hamate ligament, through here runs the ulnar nerve & artery. Compression just radial to the pisiform for 1 minute, positive test is neurological symptoms

    Flexor tendon tests

    • Anchor DIPJ’s to assess FDS
    • Note index is unreliable to test for FDS, here check pinch grip gets hyperextension of DIPJ, also flex & hold PIPJ at 90°, check DIPJ for contraction

    Finkelsteins test – De Quervain’s

    • Make a fist with the thumb in the palm, Ulna deviate the wrist
    • A positive test has pain over the abductor & EPB tendons

    Bunnel-Littler test – tight intrinsics

    • Extend the MCPJ’s & try to passively flex the PIPJ
    • If you are unable to do this, then this may mean a PIPJ contracture or tight intrinsics.
    • Thus flex the MCPJ (to relax the intrinsics), if this allows further flexion, then it is intrinsic tightness.
    • If flexing the MCPJ causes no change in PIPJ flexion, then it is a joint contracture.
    • If PIPJ flexion is ↓ with MCPJ flexion, then it is an extrinsic contracture of the long finger extensor tendons.
    • Tight retinacular ligament of Lansmere
    • Extend PIPJ, if unable to passively flex the DIPJ then this is either a tight ligament or joint contracture.
    • Thus flex the PIPJ, if this allows flexion at the DIPJ then the oblique ligament is tight.

    Instability tests

    Shear test

    • triquetrum is stabilized by applying palmer pressure over the pisiform & dorsal pressure over the triquetrum. The lunate is the manipulated relative to the triquetrum by gripping the lunate with the thumb & index finger of the other hand over the dorsal & palmer poles of the lunate respectively.
    • Discomfort or excessive translation as compared to the other side is positive.
    • Assesses the L-T ligament.

    Kirk Watson test – S-L instability

    • ref: Watson & Black “Instabilities of the Wrist” Hand Clin 3: 103, 1987.
    • Distal pole/tubercle of scaphoid is stabilized with your thumb, to restrict its palmer flexion, whilst the wrist is moved from ulnar deviation in extension to radial deviation in flexion.
    • If there is a S-L disruption, then the scaphoid will sublux dorsally when the wrist is in radial deviation & flexion, & pain will result.
    • A popping sensation may be felt as the scaphoid subluxes over the dorsal rim of the radius.
    • Releasing your thumb should allow the scaphoid to reduce & relieve pain.

    Midcarpal instability

    • Axially load the wrist as you move it from radial to ulnar deviation.
    • Jumping, catching or clunking is a positive result.
    • DRUJ instability
    • Translation of ulnar relative to radius in lateral plane
    • Clicking, popping or pain may be produced.

    Shuck test

    • Test for thumb CMCJ subluxation/instability (usually Osteoarthritis).
    • Grasp the thumb MC between your index & thumb, push & pull along the thumb axis.
    • Grinding of this joint causing pain is usually from Osteoarthritis.

    TFC injuries

    • Press test
    • Supposed to be 100% sensitive for TFC tear. Push up from chair with an extended wrist. Pain at ulnar-carpal joint is indicative of a tear.

    Compression test

    • Axially load the wrist in maximal ulnar deviation, in neutral, pronation & supination.
    • Production of pain distal to the ulnar is indicative of a tear
    • Clicking & popping may be felt.

    Circulation

    Allan’s test

    • Open & shut the hand a few times, then occlude both arteries. Next open the hand & notice the blanched palm. Release one of the arteries (usually the ulnar) & look for the return of colour.
    • Allen test for digital arteries
    • Tests the prescience of two vessels. Flex the finger & compress these, release one at a time with the finger extended. Look for return of colour.

    Capillary refill

    • Press on nails & compare
    • Must assess the elbow =/- the shoulder as well
    • Check normal Arcade of Flexion
    • Avulsion of flexor digitorum profundus (Jersey finger)
      • It occurs when the fingers of a football player are pulled into extension as he attempts to grasp the jersey of an opponent
      • Common in ring finger
      • Leads to abnormal resting arcade
        • Affected finger is in relatively extended position
    • Lacerations
      • FDP
        • Abnormal resting arcade
      • FDS
        • Only slight break in resting arcade because of pull of FDP
      • FDP / FDS
        • Loss of ability to flex DIP & PIPJ
        • Affected finger is straight
    • Finger tips
      • Felon: closed space infection of fingertip
    • Flexor tendon sheath infection
      • 4 cardinal signs of Kanavel
        • fusiform swelling extending along the middle & proximal phalanges into the distal palm
        • tender
        • finger is held in flexed position at rest
        • passive extension of finger exacerbates the patient’s pain
    • Epidermal inclusion cysts
    • Ganglion of flexor tendon sheath