Examination of the Hand Flashcards
How do we begin a hand exam?
Wash your hands
• Introduction, identification and consent
• Position the patient seated with their hands supinated and supported on a pillow
• Ask the patient of they have any pain or numbness/tingling. Take care not to cause the
patient excessive discomfort during your examination.
What are the key stages of the hand exam?
Inspection Palpation Range of motion Function Special Tests
Describe the inspection in the hand exam?
Nails: LOCAL Problems
o Pitting and/or nail ridges (seen in psoriasis)
o Onycholysis (separation of the nail from the nailbed e.g. psoriasis, fungal
infection, hyperthyroidism)
o Onychogryphosis (hypertrophic nails that resemble horns or claws: may be
post-traumatic or due to peripheral vascular disease)
SIGNS OF DISEASE ELSEWHERE
o Splinter haemorrhages, nail fold infarcts e.g. connective tissue disease/
vasculitis
o Clubbing
• DORSUM – 4 THINGS
o SKIN - Colour (pink/white/blue?) - Raynaud’s phenomenon?
▪ Changes - sclerodactyly -thickening and tethering of skin
- Ulceration due to neuropathies or severe Raynaud’s
o psoriasis
o SCARS
o MUSCLE WASTING – 1
st Dorsal interossei and guttering (ulnar nerve)
o DEFORMITY
▪ Fusiform or focal swelling e.g. dactylitis (“sausage digit”) of psoriatic
arthritis and the arthropathies associated with Ankylosing Spondylitis
(AS) or Inflammatory Bowel Disease (IBD)
▪ Nodular deformities of the interphalangeal joints (IPJs):
• Bouchard’s nodes at PIPJs in osteoarthritis (OA)
• Heberden’s nodes at DIPJs in OA
▪ Swan neck and Boutonniere deformities of IPJs in rheumatoid (RA)
▪ Squaring of the hand at the 1st carpometacarpal joint (CMCJ) in OA
▪ Windswept deformity (ulnar deviation at MCPJ in RA)
▪ Clawing - abnormal posture of peripheral nerve lesion (e.g. ulnar claw)
▪ Wrist swelling – synovitis or ganglion
• PALMER SURFACE o SKIN o SCARS o MUSCLE WASTING - thenar (median nerve) & hypothenar muscles (ulnar nerve)
o DEFORMITY - Dupuytren’s contracture
• Elbow: Inspect the elbows for rheumatoid nodules and psoriatic plaques.
What is involved in the palpation stage of the hand exam?
- TEMPERATURE - Assess using the dorsum of your hands over areas of redness
or joints. Do they feel warm or cold? - PALPATE – for tenderness, swelling or bony deformities. Start at the wrist and
palpate volar, dorsal, radial and ulnar aspects.
• Perform a squeeze test of the MCPJs (as per the GALS examination)
• If the squeeze test is painful, localise the disease by palpating each MCPJ individually.
Place both of your thumbs just distal to the MCPJ on the dorsum of the finger overlying
the extensor tendon. Your fingertips should be overlying the head of the metacarpal in
the palm.
• Palpate along the dorsal and volar aspect of metacarpals and phalanges (squeeze
gently using your thumb on the palmar surface and index finger on the dorsum).
• Palpate the radial and ulnar aspects of the phalanges. - NEURO Check sensation in the dermatomes (C6,7,8) and peripheral nerve (median,
ulnar, radial) distributions - VASCULAR
o Check ulnar and radial pulses
o Perform an Allen’s test
What is involved in the range of motion stage of the hand exam?
– 4 MOVEMENTS IN EACH AREA
Test active movement first. If a limited range of movement exists, you will need to repeat the
movement passively. Take care not to cause the patient excessive discomfort.
• Fingers
o Flexion/Extension - Ask the patient to ‘make a full fist’ then straighten fingers.
If this is not possible examine flexion of MCPJ, PIPJ and DIPJ separately.
o Abduction/adduction - Ask the patient to ‘extend and spread their fingers’ and
then back to normal.
• Thumb - flexion, extension, palmar abduction, adduction and opposition. You will
need to demonstrate to the patient what you are asking them to do e.g. “With your
hand flat, point your thumb up to the ceiling like this….”
• Wrist - Ask the patient to perform the prayer and reverse prayer signs to test the range
of dorsiflexion and palmar flexion of their wrists. You will need to demonstrate to the
patient what you are asking them to do. Then radial and ulnar deviation with elbows
by their side
How do we test function in the hand exam?
Assess grip strength
o Assess power grip by asking the patient to hold a pen in their clenched fist
and stop you pulling it out. (If not available, ask them to grip your fingers).
o Assess lateral pinch grip (key grip) by asking the patient to hold a key or a
pen normally.
o Assess precision. Can the patient undo and do up buttons?
What are the special tests for carpel tunnel syndrome (Median nerve)?
o Sensory - Test light touch in the median nerve distribution.
o Motor - Test palmar abduction against resistance (with the patient’s palm
supinated and held out flat, ask them to point their thumb vertically up to the
ceiling. Apply resistance by pushing the thumb back towards the palm with your
own thumb).
o Provocation –
• Tinel’s test - tap strongly over the median nerve as it goes through the
carpal tunnel. Reproduction of pain, numbness or tingling in the
cutaneous distribution of the median nerve is a positive test.
• Phalen’s test – ask the patient to hold both wrists in palmar flexion for
one minute. Reproduction of pain, numbness or tingling in the
cutaneous distribution of the median nerve is a positive test.
• Compression test – direct pressure over the carpal tunnel may also
reproduce symptoms
What are the special tests for ulnar nerve?
o Sensory - Test sensation in the ulnar nerve distribution
o Motor –
• Ask the patient to cross their index and middle fingers
• to grip a piece of paper between their thumb and index finger without
flexing their thumb IP joint (Froment’s sign). You will need to
demonstrate to the patient what you are asking them to do.
• To abduct their fingers against resistance
What are the special tests for the radial nerve?
o Sensory - Test sensation in the anatomical snuffbox
o Motor - Test wrist and finger dorsiflexion against resistance.
How do we complete the hand exam?
If the patient has pain or restricted movement at the wrist joint, you should also fully
examine the ipsilateral elbow. (In the OSCE, unless you are given specific instructions
to perform this assessment, you should simply state to the examiner that you would do
so).
• Thank the patient and wash your hands
