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.
- 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
- 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