Hand Exam

Note discomfort.  Note location and symmetry of findings.

Inspection

  • Posture
    • Normal concavity of the palm with slight flexion of the fingers with increasing curling of the fingers from radial to ulnar
  • Bony nodules
  • Joint swelling
    • Loss of guttering between the MCP heads when a fist is made
  • Tissue swelling
    • Ganglion (cystic tumor developing on a tendon or aponeurosis in dorsum of wrist)
    • Tendon sheath effusions
  • Nail – pitting
  • Skin – rashes, telangectasias (vasculitis, SLE, dermatomyositis)
  • Deformities
    • Ulnar drift
    • Mallet finger: flexed DIP, damage to extensor tendon
    • Boutoniere’s: hyperextended DIP, flexed PIP
    • Swan neck: flexed DIP, hyperextended PIP
    • Heberden’s/Bouchard’s: hard dorsal lateral nodules of DIP/PIPs
    • Dupuytren’s: flexion deformity of the fingers at the MCP and IPs, associated with DM, alcoholism, and hereditary



 

ROM

  • Active then passive
  • Wrist – flexion to 90° and extension to 70°, pronation and supination, radial/ulnar deviation
  • Fingers – abduction, adduction, opposition
    • Normal flexion would bring the fingers to the distal palmar crease
    • If limited, note fingertip to palm distance
  • Grip strength
    • Grip on a rolled up and partially inflated (to 30 mm Hg) BP cuff (normal: ~ 140 mm Hg)

Palpation

  • DIP, PIP, MCP, CMC, Ulnar styloid, Tendons
    • Note pain, warmth, swelling, instability
    • PIPs, DIPs: 4 finger method
    • Ulnar stability: stabilize the radial scaphoid joint, try pressing ulnar styloid up and down
    • Anatomic snuffbox – scaphoid fracture
  • Synovitis – bogginess, and elicitation of fluid by fluctuation
  • OA (Bouchard’s, Heberden’s) – hard bony swelling

Special tests

  • Palmar tenosynovitis and trigger finger
    • Inflammation of the flexor tendon sheaths → localized tenderness on palpation
    • Middle and index fingers are most commonly affected
    • A nodule may develop during the healing process (found just proximal to the MCP in the palm)
      • These painless nodules may be associated with crepitus, and interfere with the normal tendon gliding and can cause an uncomfortable triggering or locking, which may be intermittent
      • Passive ROM is greater than activ
  • Quervain’s tenosynovitis
    • inflammation of the tendon sheath of the APL (abductor pollicus longus) and EPB (extensor pollicus brevis)
    • Finklestine’s test
      • Ask patient to flex the thumb and close the fingers over it, then attempt to move the hand into ulnar deviation
      • Falsely positive with OA of the first CMC join
  • Carpal tunnel syndrome
    • Ask patient to point out the distribution of pain on a hand diagram
    • Neurological signs and provocative tests are positive late in the disease
    • Tinel’s test
      • Tap the MEDIAN nerve as it courses medial to the FLEXOR RADIALIS underneath the transverse carpal ligament
      • Positive sign is reproduction of the tingling in the median nerve distribution
    • Phalen’s test
      • Hyperflexion of the wrists

OA                                          RA

Distribution                       DIP, PIP, 1st CMC                  MCP, PIP

Swelling                            Hard                                        Boggy

Warmth                             +                                              +++

Fluid                                  -/+                                            +++

Deformity                         DIP                                         MCP, PIP, wrist

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