Examination of the Hand

Examination of the Hand

Special Tests

Nerve Palsy Examination

Deformities

  • Ape Hand
    • Thenar wasting, thumb held in line with fingers (extorens tendon pull)
    • Median Nerve palsy
  • Bishops Hand
    • Also called Benediction hand
    • Hypothenar wasting, intrinsic wasting, partial claw of the ulna side
    • 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

  • Posterior Interosseous
    • 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

  • General
    • 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

Allen’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
  • 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
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