Hand Examination

• Hand examination follows a simple structure that is easy to remember:
  • Look
  • Feel (+neurovascular testing)
  • Move
  • Special Tests
• Within the history it is important to note the patient’s description of the injury, current pain level (0-10 scale) and blood loss/active bleeding. This will guide your examination.

START WITH DORSUM OF THE HAND

• Skin
  • Discolouration
    • White (arterial insufficiency)
    • Erythema (cellulitis/infection)
    • Blue/purple (venous congestion)
  • Benign lesions (Heberden’s nodes, Garrod’s pads)
  • Malignant lesions (SCCs, melanomas, actinic keratoses)
• Nails
  • Trauma
  • Signs indicating systemic co-morbidities
    • Clubbing
    • Pitting
    • Koilonychia
    • Thickening/discolouration
• Swelling
  • Oedema
  • Trauma related
  • Dorsal wrist ganglion
• Deformity
  • Absence of normal anatomy
  • Asymmetry with another limb
  • Rotation of digits

TURN THE HAND OVER AND LOOK AT VOLAR SURFACE

• Skin
  • Scars, palmar nodules (Dupuytren’s)
• Swellings
  • Oedema
  • Trauma
  • Volar wrist ganglion
• Wasting
  • Thenar
    • Median nerve involvement (?Carpal tunnel syndrome)
  • Interossei
    • Ulnar nerve involvement (?Cubital tunnel syndrome)

• General
  • Temperature
    • Hot
      • Indicates infection or inflammation
    • Cool
      • Indicates a vascular pathology
      • Need to test NV status
  • Tenderness
  • Joint effusion
  • Masses
  • Crepitus/Clicking/Snapping
• Assess blood supply
  • Radial and ulnar pulses
  • Modified Allen's Test
  • Capillary refill
• Assess sensation in each nerve territories
  • Median
  • Ulnar
  • Radial
• Feel the relevant feature
  • If a joint is affected
    • Range of movement
    • Stability

ACTIVE/PASSIVE

• If possible, isolate each joint
• Assess passive ROM
• Assess active ROM (global and area of interest)
  • Finger and wrist flexion/extension
  • Finger abduction/adduction
  • Thumb flexion/extension/abduction/retropulsion
  • Finger opposition

RANGE OF MOVEMENT

• Fingers have a normal ROM of roughly:
  • MCP: 0° extension to 85° flexion
  • PIP: 0° extension to 110° flexion
  • DIP: 0° extension to 65° flexion
• Wrist has a normal ROM of roughly:
  • 60° flexion
  • 60° extension
  • 50° radioulnar deviation arc

RADIAL

• Look for
  • Wrist drop.
  • Wasting of the triceps, brachioradialis and extensor compartment.
• Motor
  • Testing triceps: ask the patient to extend at their elbow joint.
  • Test ECRL an ECRB tendons: ask the patient to extend the wrist and test radial deviation.
  • Test the Extensor Pollicis longus (EPL): thumb retropulsion with the palm flat on a surface.
• Sensory
  • Test the sensation within the first web space
    • Sharp/blunt sensation
    • Two-point discrimination

ULNAR

• Look for
  • Hypothenar wasting
  • Ulnar claw hand
  • Interosseus guttering
• Motor
  • Froment’s test (for adductor pollicis): ask the patient to hold a piece of paper in between his thumb and his index finger (with all digits flexed).
  • First dorsal interosseus and abductor digiti minimi test: resisted abduction of the digits
  • FDM test: flex little finger at the MCPJ with PIP straight
  • Ulnar-innervated FDPs: test the flexion of the DIPJ of ulnar two fingers (ring and little)
• Sensory
  • Test the sensation in the little finger
    • Sharp/blunt sensation
    • Two-point discrimination

MEDIAN

• Look for
  • Thenar musculature wasting
  • Sudomotor changes within the nerve division.
• Motor
  • Anterior interosseus n. sign: ask the patient to make an “O” with the index and the thumb. If they cannot, this means there is denervation of the FDP and FLP.
  • Quadratus test: ask the patient to pronate their forearm with elbow extended.
  • Motor branch affected if:
    • Weak thumb abduction
    • Weak opposition of the little finger
• Sensory
  • Testing the index finger pulp
  • Sharp/blunt sensation
  • Two-point discrimination
  • Tinel’s sign
    • Tapping on the volar wrist elicits paraesthesia in the distribution of the nerve