Hand Examination Flashcards
1
Q
How should a patient be positioned for a hand exam?
A
Exposed up to the elbow. Hands on lap, on pillow with palms down.
2
Q
What are the sections of a hand exam?
A
Look, feel, move, function
3
Q
Summarise what your are looking for in the ‘look’ section?
‘Delightfully confused tasty sluts followed Jonny Marr’
A
Deformity Colour Temperature Skin changes Fingernails Joints Muscles
4
Q
Summarise deformities?
A
- Diagnostic - eg. flexed arm and hand of hemiplegia or radial nerve palsy, or ulnar deviation at MCP joints in RA.
- Bouchard’s/ Heberden’s nodes - distal/proximal IP joints - OA.
- Dupuytren’s contracture - thickening of palmar fascia causing fixed flexion deformity.
- Arachnodactyly - long thin fingers, typical of Marfan’s syndrome.
- Trauma
5
Q
Summarise colour?
A
- Cyanosis in nail bed.
- Tobacco staining of fingers
- Pigmentation in skin creases.
6
Q
Summarise temperature?
A
- In COPD the hands may be cyanosed due to reduced arterial oxygen saturation but warm due to vasodilatation from elevated arterial CO2 levels.
- In HF hands are often cold and cyanosed due to vasoconstriction in response to low cardiac output. If warm, heart failure may be due to a high output state such as hyperthyroidism.
7
Q
Summarise skin?
A
- Dorsum of skin is smooth and hairless in children and in adult hypogonadism.
- Manual work may produce specific callosities due to pressure at characteristic sites.
- Disuse results in soft, smooth skin, as seen on the soles of the feet in bed bound patients.
- Look at flexor surfaces of wrists and forearms. Not any venepuncture marks of IV drug use and linear (usually transverse) multiple wounds or scars from self-harm.
8
Q
How do you examine for clubbing?
A
- Look across the nail bed from the side of each finger. Osberve the distal phalanges, nail and nail bed.
- Measure the anteroposterior distance (interphalangeal depth) at the level of the DIP joint. Repeat at level of nail bed.
- Measure the nail bed angle.
- Place nails or corresponding fingers back to back and look for a visible gap between the nail beds (Schamroth’s window sign).
- Place thumbs under pulp of distal phalanx and use your index fingers alternately to see if you can feel movement of nail on the nail bed. This is fluctuation.
9
Q
What are the conditions for clubbing being present?
A
- Interphalangeal depth ratio is >1.
- Normal nail foldangle is 190 degrees.
- Schamroth’s window sign is absent.
- Increased nail bed fluctuation may be present but its presence is subjective and less discriminatory than the other features.
10
Q
Summarise joints?
A
- RA affects MCPJs and PIPJs and OA typically affects DIPJs.
- Bouchard’s nodes in the PIPJs, and Heberden’s nodes in the DIPJs are both indicative of OA.
- Swan neck deformity = DIPJ hyperflexion with PIP hyperextension - RA.
- Z-thumb = hyperextension of IP joint, fixed flexion and subluxation of MCP joint.
- Boutonniere deformity = PIPJ flexion with DIPJ hyperextension - RA.
11
Q
Summarise muscles?
A
- Small muscle wasting of hands common is RA, producting dorsal guttering of the hands.
- In carpal tunnel, median nerve compression leads to wasting of thenar muscles.
12
Q
What are you looking for when feeling elbows/arms?
A
Palpating for nodules/tenderness
13
Q
Summarise feeling palms?
A
- Thenar/hypothenar bulk - wasting noted in ulnar/median nerve lesions.
- Temperature - wrist and MCP join lines - warm joints may indicate inflammatory/septic arthritis.
- Tenderness
- Palmar thickening - dupuytren’s contracture.
- Radial pulse - palpate pulses to ensure adequate arterial supply to the hand.
14
Q
Summarise feeling dorsum?
A
- Palpate joints of the hand a wrist - assess for tenderness/irregularities/warmth.
- Wrist, MTP joint, PIP joint, DIP joint.
- MCP squeeze - often tender in RA/other inflammatory arthropathies.
- Anatomical snuffbox - tenderness may suggest scaphoid fracture.
15
Q
Assessing sensation?
A
Median nerve - thenar eminence
Ulnar nerve - hypothenar eminence
Radial nerve - first dorsal web space.
