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MRCS B Examinations and practical skills > Hand examination > Flashcards

Hand examination Flashcards

1
Q

Look

A

-Expose with sleeves up to elbows
-Ask pt to rest hands on pillow/desk
-Check posture and position of hand (cascade, clawing, rotation)
-Inspect volar aspect
-Turn hand over, inspect dorsal aspect
-Look at elbows for RA nodes or psoriatic plaques
-Ears for gouty tophi

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2
Q

What is normal cascade of hand?

A

Digits are flexed at MCPJ and IPJs, more on ulnar than radial side

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3
Q

Inspection volar aspect:

A

-Scars
-Nodules
-Contractures
-Pits/bands/cords
-Palmar erythema
-Muscle wasting esp. in thenar/hypothenar eminences

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4
Q

Inspection dorsal aspect

A

-Scars
-Nails and nail folds
-Digits: nodules, joint deformities, subluxation
-Hand: skin quality, bruising, discolouration, rashes, muscle wasting

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5
Q

Feel

A

-Ask if any specific area discomfort
-Assess capillary refill time + consider Allen’s test (compromised circulation in palm suggestive of radial/ulnar artery pathology)
-Feel radial and ulnar pulses
-Assess temperature (dorsal and volar B/L)
-Bimanually palpate DIPJ, PIPJ, MCPJ
-Feel muscle bulk in thenar + hypothenar + compare B/L
-Feel for dupuytren’s disease/snuffbox

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6
Q

What bony swellings might you palpate on bimanual palpation?

A

-Squaring CMC joint of thumb (OA)
-Heberden’s nodes (OA)
-Bouchard’s nodes (RA)

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7
Q

Move

A

-Straighten all fingers then make fist
-Wrist flexion/extension
-Assess flexor and extensor function of each digit (FDS and FDP), passively if active not possible
-Assess movements of thumb: flexion, extension, abduction (adduction and opposition tested in pincer/picking up object)
-Check druj (rock radius and ulnar to check for stability: abnormal in RA/previous wrist fracture
-Test functional capacity

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8
Q

How would you test FDS and FDP?

A

-FDP: stabilise PIPJ, ask pt to flex at DIPJ
-FDS: Isolate finger being examined by holding other fingers in extension, then ask pt to flex at PIPJ

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9
Q

How would you test thumb extension?

A

-Ask pt to place hand on table and raise thumb off table
-Feel for integrity of EPL tendon
-In RA/post colles #, EPL may undergo attrition rupture as tendon swings around dorsal radial tubercle (lister’s tubercle)

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10
Q

How would you test thumb flexion/abduction/opposition

A

-Abduction: ‘thumb to ceiling (palmar side up), stop me from pushing it down’
-Flexion: as FDS/FDP
-Opposition and adduction: pincer grip

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11
Q

How would you test wrist flexion/extension?

A

Prayer
Reverse prayer

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12
Q

How would you test functional capacity of hand?

A

-Grip your two fingers to test for power grip
-Pinch your finger to test for pincer grip
-Pick up small object: this will test for pincer grip and function

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13
Q

Neurological assessment of hand

A

-Test median nerve: If any loss of function evaluate for evidence carpal tunnel with Phalen’s/Tinel’s test
-Test ulnar nerve
-Test radial nerve
-Test sensation in radial, median and ulnar distribution (light touch and pin prick)

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14
Q

How would you test median nerve?

A

-OK sign: flexion of IP joint of thumb and DIPJ index finger impaired

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15
Q

Phalen’s test

A

-Passively hyperflex pt’s wrists + hold that position for 1 minute
-Test is +ve if pt reports numbness, tingling or pain in distribution of median nerve

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16
Q

Tinel’s test

A

-Tap lightly over carpal tunnel
-Test is +ve if pt reports numbness/tingling/pain in distribution of median nerve

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17
Q

How to test ulnar nerve

A

-Ask pt to cross/scissor middle and index fingers together: tests abduction and adduction
-Test palmar interossei: adduct fingers (sheet of paper)–> PAD
-Test dorsal interossei: Abduct fingers–> DAB
-Froment’s test (tests adductor pollicis)

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18
Q

What is froment’s test?

A

-Ask pt to grasp piece of paper between index finger and thumb
-Can then pull paper away
-If ulnar nerve lesion, distal phalanx of thumb flexes (due to action of unaffected FPL) to compensate for weak muscle (adductor pollicis) that is supplied by ulnar nerve
-This is +ve froment’s sign

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19
Q

Radial nerve

A

-Supplies muscles in extensor compartment
-To test radial nerve motor function ask pt to extend fingers and wrist against resistance

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20
Q

Autonomous sensory zones

A

Radial nerve: dorsal first webspace
Median nerve: Distal pad index finger
Ulnar nerve: Distal pad little finger

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21
Q

Hand examination summary:

A

Look:
–> posture + cascade
–> Volar
–> Dorsal

Feel
–> CRT
–> Temperature
–> Bimanual palpation
–> Muscle bulk thenar/hypothenar
–> Dupuytren’s

Move
–> Functional assessment
–> FDS + FDP

22
Q

To complete examination:

A

Offer allen’s test
Neurovascular examination of the upper limbs.
Examination of the elbow joint and shoulder joint.
Further imaging if indicated (e.g. X-ray and MRI).
Consider further investigation e.g. nerve conduction studies

23
Q

Bloods for rheumatological condition

A

-FBC (anaemia chronic disease)
-U + E
-CRP
-ESR
-RF
-ANA

24
Q

Tips while examining hand: Think of structures you are examining

A

-Nail/nail bed
-Skin
-Subcutaneous tissue
-Palmar fascia
-Tendon
-Joint/synovium
-Bone

25
Q

Describe pathology of dupuytren’s disease

A

-Dupuytren’s contracture
-Palmar aponeurosis is susceptible to progressive hyperplasia and fibrosis, with subsequent thickening and shortening
-Leads to flexion deformity of one or more digits, with associated loss of function

26
Q

Which digits does dupuytren’s most commonly affect?

A

Ring and little fingers

27
Q

What other fibromatous conditions are associated with dupuytren’s disease?

A

Plantar fibromatosis (Lederhosen disease) – affecting the sole of the foot
Peyronie’s disease – affecting the penis
Garrod disease – affecting knuckle pads

28
Q

What is a trigger finger?

A

Thickenining/stenosis of A1 pulley
-Causes tendon to catch/lock PIPJ as pt extends finger

-Also known as stenosing tenosynovitis
-Is due to mismatch between thickened/stenotic first annular (A1) pulley in hand and the tendon trying to glide through pulley
-This causes the flexor tendon to catch or lock PIPJ as pt attempts to extend finger
-Results in difficulty flexing or extending finger known as ‘triggering’ phenomenon

29
Q

Describe ‘Jersey finger’ type injury

A

Traumatic FDP avulsion from base of distal phalanx due to hyperextension DIPJ
-Commonly affects ring finger

-Traumatic FDP avulsion from tendon-bone junction at its insertion into distal phalanx following hyperextension of DIPJ which subjects FDP tendon to excessive load
-Can occur if finger is caught in jersey
-Commonly affecgts ring finger

30
Q

Describe most common mechanism of mallet injury

A

-Avulsion of extensor tendon apparatus at DIPJ
-Most common mechanism is forced hyperflexion of DIPJ e.g. when ball strikes tip of finger
-Pt is unable to extend finger at DIPJ

31
Q

How would you manage mallet finger injury?

A

-Mostly conservative in mallet splint for 6-8 weeks (to keep DIPJ extended until healing complete)
-Surgical repair may be necessary (dermatotenodesis/open repair +/- k wire) if there is large bone fragment or poor alignment

32
Q

Describe features of rheumatoid hand

A

-Ulnar deviation of wrist: volar subluxation of carpus from ulnar
-Subluxation: volar and ulnar subluxation of MCPJs
-Swan neck deformity: Hyperextension at PIPJ and flexion at DIPJ
-Boutonniere deformity: Flexion at PIPJ and extension at DIPJ
-Z-shaped thumb: Flexed CMCJ and IPJ with extended MP joint

33
Q

Describe investigations for rheumatoid hand

A

-XR
-Bloods for rheumatoid factor, ana, anti ccp

34
Q

Describe management of rheumatoid hand

A

Conservative:
–>Physiotherapy and splinting

Medical
–> NSAIDs and corticosteroids (first line)
–> DMARDs (e.g. azathioprine, methotrexate) second line

Indications for surgery
-pain
-loss of function
-Deterioration in function

Surgical techniques
-Synovectomy (due to inflammation)
-Arthroplasty
-Tendon transfer
-arthrodesis (fusion)

35
Q

Describe anatomy of brachial plexus

A

see image

36
Q

What are the common obstetric brachial plexus injuries?

A

-Upper trunk (c5,C6): adducted and internally rotated arm with extended elbow and pronated forearm (Erb’s palsy)
-Usually due to shoulder dystocia during birth

-Injury to lower trunk brachial plexus (C8-T1) results in wasting of intrinsic muscles of hand (klumpke’s palsy)
-Usually due to traction on abducted arm during childbirth
-Classic presentation is of a clawed hand
-Involvement of T1 pay result in Horner’s syndrome

37
Q

Where can median nerve commonly be damaged and what are the mechanisms?

A

-Carpal tunnel. Mechanism: compression of median nerve within carpal tunnel
-At elbow. Mechanism: supracondylar fracture
-At wrist. Mechanism: Lacerations just proximal to flexor retinaculum

38
Q

Describe carpal tunnel syndrome: risk factors, mechanism, symptoms, tests, treatment

A

-Risk factors: pregnancy, acromegaly, diabetes
-Mechanism: compression within carpal tunnel
-Numbness +/- weakness in median nerve distribution
-Tests: tinel’s/phalen’s
-Treatment:
–> conservative: spinting to hold in extension overnight
–> medical: corticosteroid injections into carpal tunnel
–> surgical: carpal tunnel decompression

39
Q

Describe symptoms of carpal tunnel

A

-Numbness/tingling median nerve distribution
-Palm spared
-Can progress to weakness

-Symptoms: numbness/tingling in radial nerve distribution (thumb, fingers up to ulnar half ring finger). Palm spared as palmar cutaneous nerve does not travel through carpal tunnel
-If left untreated can lead to weakness + atrophy of thenar muscles

40
Q

Injury to median nerve at elbow:

A

-Mechanism: supracondylar fracture

Motor loss
–> flexors and pronators lost except FCU: weak flexion of wrist with ulnar deviation, forearm supinated
–> FPL and superficial head FPB lost: cannot flex thumb
–> Lateral two lumbricals denervated: cannot flex MCPJ/extend IPJ

Sensory loss
–> cutaneous innervation to lateral hand up to ulnar half ring. NOT arm (lateral and medial cutaneous nerves forearm)

Signs
–> Thenar eminence wasting
–> hand of benediction

41
Q

Describe hand of benediction

A

If patient tries to make a fist, only the little and ring fingers can flex completely

42
Q

Describe median nerve lesion at wrist

A

-Mechanism: lacerations just proximal to flexor retinaculum
-Motor: Thenar + lateral two lumbricals paralysed. Affects opposition of thumb + flexion of middle and index fingers
-Sensory: same as elbow
-Signs:
–> hand of benediction

43
Q

How would you identify median nerve in brachial plexus?

A

M

44
Q

Where can ulnar nerve be damaged?

A

Medial epicondyle, cubital tunnel, anterior wrist

-Elbow. Mechanism: damage to medial epicondyle at elbow, entrapment in cubital tunnel
-Wrist. Mechanism: lacerations to anterior wrist

45
Q

Describe borders cubital tunnel

A

Medial wall – medial epicondyle of the humerus.
Lateral wall – olecranon of the ulna.
Floor – elbow joint capsule and medial collateral ligament of the elbow.
Roof – ligament spanning between the medial epicondyle and olecranon

46
Q

Describe ulnar nerve injury at elbow:

A

-Mechanism: medial epicondyle fracture/entrapment in cubital tunnel

-Motor:
–> Flexion of wrist with radial deviation due to denervation FCU and medial two lumbricals
–> Loss of finger abduction/adduction (paralysis interossei)
–> Movement to 4th + 5th digits impaired (loss of medial two lumbricals and hypothenar muscles)
–> Adduction of thumb lost and +ve froment’s sign (loss of adductor pollicis)
–> Sensory: medial hand and radial 1.5 fingers

Signs
–> cannot grip paper between two fingers
–> +ve froment’s sign
–> wasting hypothenar muscles

47
Q

Describe ulnar nerve damage at the wrist:

A

Mechanism: laceration to anterior wrist

Motor functions:
-Only the intrinsic muscles of the hand are affected.
-Abduction and adduction of the fingers cannot occur (due to paralysis of the interossei).
-Movement of the 4th and 5th digits is impaired (due to paralysis of the medial two lumbricals and hypothenar muscles).
-Adduction of the thumb is impaired, and the patient will have a positive Froment’s sign (due to paralysis of adductor pollicis)

Sensory:
-The palmar branch and superficial branch are usually severed, but the dorsal branch is unaffected. This results in sensory loss over palmar side of medial one and a half fingers only

Signs
-Patient cannot grip paper placed between fingers, positive Froment’s sign, wasting of hypothenar eminence

48
Q

Where can the radial nerve be damaged?

A

Axilla. mechanism: dislocation of shoulder joint, or fracture proximal humerus. Excessive pressure on nerve at axilla, e.g. ill-fitting crutch

Radial groove: # humeral shaft

Forearm: superficial branch (stabbing or laceration of forearm), Deep branch (fracture of radial head, posterior dislocation radius)

49
Q

Describe radial nerve lesion in axilla

A

Motor functions
-Unable to extend forearm/wrist/fingers
-Wrist drop

Sensory
-Lateral and posterior surface of arm, posterior forearm, dorsum of radial hand and 3.5 digits

Motor functions – the triceps brachii and muscles in posterior compartment are affected. The patient is unable to extend at the forearm, wrist and fingers. Unopposed flexion of wrist occurs, known as wrist-drop.

Sensory functions – all four cutaneous branches of the radial nerve are affected. There will be a loss of sensation over the lateral and posterior arm, posterior forearm, and dorsal surface of the lateral three and a half digits

50
Q

Describe radial nerve lesion in radial groove

A

-Wrist drop/loss of finger extension/weakened elbow extension
-Only sensation to dorsal hand compromised

Motor functions
The triceps brachii may be weakened, but is not paralysed (branches to the long and lateral heads of the triceps arise proximal to the radial groove).

Muscles of the posterior forearm are affected. The patient is unable to extend at the wrist and fingers. Unopposed flexion of wrist occurs, known as wrist-drop.

Sensory functions – the cutaneous branches to the arm and forearm have already arisen. The superficial branch of the radial nerve will be damaged, resulting in sensory loss to the dorsal surface of the lateral three and half digits and the associated area on the dorsum of the hand.

51
Q

Describe radial nerve lesion in forearm

A

Superficial branch: stabbing or laceration to forearm
–> Motor: none
–> Sensory: Sensory loss affecting the lateral 3 ½ digits, and associated the associated area on the dorsum of the hand

Deep branch: Fracture radial head/posterior dislocation of radius
–> Motor: Majority of the muscles in posterior forearm are affected. Wrist-drop does not occur, as the extensor carpi radialis longus is unaffected, and maintains some extension at the wrist
–> sensory: None

MRCS B Examinations and practical skills (13 decks)

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