Hand examination Flashcards
What is the first part of any introduction to an examination?
Wash hands
Intro self
Pt details
Explain a hand exam to a patient
I’ve been asked to examine your hand today, it’s going to involve me having a general inspection, feel, asking you to perform some movements and then performing some special tests, would that be okay?
What else would you include in your intro?
Pain or discomfort?
When inspecting the nails in a hand exam what do you look for?
What can these changes indicate?
Pitting and/or nail ridges -> Psoriasis.
Onycholysis -> Psoriasis/fungal infection/hyperthyroidism.
Hypertrophic nails that resemble claws ->
Post-traumatic or peripheral vascular disease.
Splinter haemorrhages
Clubbing.
When looking at the dorsum of the hand what are you looking for?
What do changes indicate?
Skin ->
- Colour (pink/white/blue) -> Raynaud’s phenomenon /
cyanosis
- Changes -> Sclerodactyly (thickening and tethering of
skin).
Ulceration due to neuropathies.
Psoriasis.
Scars.
Muscle wasting -> 1st dorsal interossei/guttering (ulnar
nerve).
Deformity -> Focal swelling like dactylitis
= Psoriatic arthritis.
= Arthropathies associated with ankylosing
spondylitis or IBD.
Nodular deformities ->
- Bouchard’s nodes at the PIPJs (OA).
- Heberden’s nodes at the DIPJs (OA).
Swan neck + Boutonniere deformities IPJs in RA.
Ulnar deviation MCPJ in RA.
Clawing -> Abnormal posture of peripheral nerve lesion
(ulnar claw).
Wrist swelling -> Synovitis or ganglion.
When looking at the palmar surface of the hand what are you looking for?
Skin.
Scars.
Muscle wasting -> Thenar (median nerve) and hypothenar
(ulnar nerve) muscles.
Deformity
Dupuytren’s contracture.
What do you inspect the elbow for in a hand exam?
Rheumatoid nodules
Psoriatic plaques
What do you palpate / rest in the feel portion of the hand exam?
Temperature
Every bone/joint
Lateral MCP squeeze
Palpate the anatomical snuffbox
Sensation in the C6–8 dermatomes.
Sensation in the median, ulnar and radial nerve distributions.
Check ulnar and radial pulses.
Perform Allen’s test.
When palpating the bones and joints of the hand what is the best way to do this?
Start at the rest and palpate every bone/joint using 2 hands for the palm and 4 fingers for the joints.
Feel joints from wrist to the metacarpals by sliding the thumb distally.
What active movements do you test in the hand exam?
What instructions do you give to the patient?
Fingers –
- Flexion/extension;
“Can you make a full fist for me and then straighten
your fingers”.
- Abduction/adduction;
“Can you now spread your fingers apart and bring
them together”.
Thumb –
- Flexion/extension;
“Move your thumb to the side and back together”.
- Abduction/adduction;
“Point your thumb to the ceiling and back down”.
- Opposition;
“Touch your thumb and little finger together”.
Wrist –
- Dorsiflexion;
“Can you make a prayer sign for me and keep your
elbows straight”.
- Palmer flexion;
“Can you now reverse that and keep your elbows
straight”.
What tests do you use to test grip strength in a hand exam?
What do you ask the patient?
Lateral pinch grip;
- Ask patient to hold a key/pen normally.
Power grip;
- Ask patient to hold a pen in their clenched fist and stop
you from pulling it out (or just grip fingers).
Precision grip;
- Can you undo and do up buttons?
What special tests can be used to assess the following?
a) median nerve sensation
b) median nerve motor function
c) provocation tests for carpal tunnel syndrome
a) Sensation – Light touch in median nerve distribution.
b) Motor – Thumb palmar abduction against resistance
“Point your thumb to the ceiling and don’t let me push
it down”.
c) Tinel’s test - Tap strongly over the median nerve.
Phalen’s test - Reverse prayer sign for one minute.
Compression test - Direct pressure over the carpal
tunnel can reproduce symptoms.
What special tests can be used to assess the following?
a) ulnar nerve sensation
b) ulnar nerve motor function
a) Sensation – Light touch in ulnar nerve distribution.
b) Motor –
Ask patient to cross their index and middle fingers.
Ask patient to grip paper between their thumb and index finger without flexing their thumb IP joint (demonstrate). Finger abduction against resistance.
What special tests can be used to assess the following?
a) radial nerve sensation
b) radial nerve motor function
Sensation – Light touch in radial nerve distribution.
Motor – Test wrist and finger dorsiflexion against
resistance.
Upon completing the exam what do you do first?
Thank patient
Wash hands
