Examination of the Hand
Look
Start examination by asking " Do you have RA?"
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