Hand exam

Question 1

What are you looking for on general inspection in a hand exam?

Answer 1

• scars
• wasting of muscles
• aids and adaptions (splints)

Question 2

What are you looking for on closer inspection in a hand exam?

Answer 2

• Hand posture: dupuytren’s contracture or claw hand (ulnar nerve pathology)
• Scars: previous surgery/trauma
• Swelling: e.g. dactylitis in inflammatory arthritis or IBD
• Muscle wasting: LMN pathology (e.g. thenar wasting in carpal tunnel syndrome
• Skin colour: erythema or Raynaud’s
• Nodes: Bouchard’s (PIPJ) or Heberden’s (DIPJ) in osteoarthritis
• Deformities: swan-neck, z-thumb, ulnar deviation, or boutonnieres in rheumatoid arthritis
• Nail pitting and onycholysis: psoriasis
• Psoriatic plaques: on dorsum of hands or elbows
• Sings of infective endocarditis: splinter haemorrhages, janeway lesions, osler’s nodes

Question 3

What are you looking for when feeling the palms in a hand exam?

Answer 3

• Temperature
• Radial and ulnar pulse (perform Allen’s test)
• Thenar and hypothenar eminence (for wasting = LMN lesion)
• Palmar thickening (dupuytren’s contracture)
• Sensation (median nerve = thenar eminence and index finger, ulnar nerve = hypothenar eminence and little finger)

Question 4

What are you looking for when feeling the dorsum in a hand exam?

Answer 4

• Temperature
• Radial nerve sensation (1st dorsal webspace)
• Anatomical snuffbox (tenderness suggests scaphoid fracture)
• MCP joint squeeze (tenderness suggests inflammatory arthropathy)
• Individual joint palpation (for tenderness, irregularities, and warmth)
• Wrist palpation (for joint line irregularities, warmth, and tenderness)

Question 5

How do you asses movement in a hand exam?

Answer 5

Active:
- finger flexion/extension (make fist and straighten)
- finger abduction/adduction (spread fingers and close)
- wrist extension/flexion (prayer and reverse prayer sign)
- wrist ulnar/radial deviation (with elbows by side, tilt hands each side)
- thumb extension/flexion (thumbs to side of fingers, and out)
- thumb abduction/adduction (thumbs to ceiling, join to fingers and extend)
- thumb opposition (join thumb to little finger)
Passive:
- repeat above movement, isolating each joint)

Question 6

How do you assess function in a hand exam?

Answer 6

• power grip: squeeze fingers with fists
• pincer/key grip: squeeze finger/hold object with thumb and index
• precision: pick up small object/do up buttons

Question 7

What are the special tests for the median nerve in a hand exam?

Answer 7

• Test sensation of thumb, index, middle, and half of ring finger
• Test thumb abduction against resistance (thumb to ceiling, push down)
• Tinel’s test: tap over carpel tunnel, tingling/numbness in median nerve distribution is a positive sign for medial nerve compression
• Phalen’s test: hold reverse prayer sign for 60 seconds, tingling/numbness in medial nerve distribution is a positive sign for carpal tunnel syndrome

Question 8

What are the special tests for the ulnar nerve in a hand exam?

Answer 8

• Test sensation of little, and half of ring finger on palm or dorsum
• Abduct fingers against resistance (spread fingers and push together)
• Cross index and middle fingers
• Grip paper between index finger and thumb without bending thumb, positive sign is needing to bend thumb (ulnar nerve lesion)

Question 9

What are the special tests for the radial nerve in a hand exam?

Answer 9

• Test sensation of dorsum of thumb and MCP of index finger
• Test wrist/finger extension against resistance (cock wrists back with fingers straight, push down)

Question 10

How do you complete a hand exam?

Answer 10

• Examine the elbow joint
• Perform a neurovascular examination of the upper limbs