Video

http://geekymedics.com/2010/10/05/hand-examination/

Exam Summary


1. Introduction

  • Introduce yourself and the exam
  • Ask if the patient has any pain
  • Hand hygiene
  • Give the patient a pillow to put under their arms
  • Ask the patient what their dominant hand is.

2. General Inspection

Inspect the wrist, hands and elbows. Look for:
heberdens-nodes.jpg
Bouchard's and Heberden's nodes
Swan_neck_deformity.jpg
Swan neck deformity of ring finger
Rheumatoid Arthritis2.jpg
Ulnar deviation and Z-thumb

Boutonnière_deformity.jpg
Boutonniere's deformity
Carpal Tunnel Syndrome.jpg
Thenar muscle wasting
640px-Morbus_dupuytren_fcm.jpg
Dupuytren's Contracture
rheumatoid_nodules.jpg

3. Palpation

a. General

Start at the elbow and move more distally.
  • Feel along the forearms
  • Assess Temperature of the back of the hand
  • Feel for radial pulse and ulnar pulse - may be absent in arterial disease
  • Test capillary refill (should be <2 seconds)
radialpulse.jpg
Radial Pulse

b. Joints

  • Assess the joints of the hands for:
    • Stability
    • Swelling
    • Tenderness
    • Deformity
    • Crepitus
  • Palpate the anatomical snuffbox for a possible scaphoid fracture

c. Nerves

  • Radial nerve can be assessed by touching the dorsal side of the hand between the thumb and index finger
    Hand nerves.jpg
    Cutaneous Distribution of hand nerves
  • Median nerve can be assessed by touching over the thenar muscles
  • Ulnar nerve can be assessed by touching over the hypothenar muscles

4. Movement

  • Wrist Extension (prayer sign) - normal range is 70⁰
  • Wrist Flexion (bring backs of hands together) - normal range in 90⁰
  • Wrist Ulnar deviation - normal range in 55⁰
  • Wrist Radial deviation - normal range in 20⁰
  • Metacarpophalangeal (MCP) joint extension/flexion - Test for palmar tendon crepitus by placing palmar aspect of fingers against the palm of the patient’s hand while they flex/extend MCP joints. If inflamed, tendons can be felt creaking in their sheathes and nodules may be palpable. Indicates tenosynovitis. A Trigger Finger may also be detected where the flexion occurs freely up to a certain point where it sticks and cannot be extended (due to jamming in a narrowed part of the tendon sheath). Rheumatoid Arthritis is a cause.
  • Ask the patient to make a fist (Finger flexion)
  • Ask the patient to spread their fingers (Finger extension)
  • Ask the patient to oppose their thumb and fingers
  • Pronation and Supination of wrist
  • Passively flex and extend the Metacarpophalangeal Joints (MCP), Proximal Interphalangeal Joints (PIP) and the Distal Interphalangeal Joints (DIP)

5. Function

  • Assess Finger Extension and Finger Flexion power
  • Assess Finger Adduction and Abduction power
  • Assess Thumb Abduction power
  • Ask patient to squeeze your finger (Power Grip)
  • Ask patient to squeeze your finger only between their thumb and index finger (Pincer grip)
  • Ask the patient to pick up a coin or do up a button (Dexterity)

6. Special Tests

  • Phalen's Test - reverse prayer sign for 30 seconds
  • Tinel's Test - tap flexor retinaculum. If there are pins and needles, it suggests Carpel Tunnel Syndrome.


7. Conclude

Thank the patient and offer assistance

See Also

Geeky Medics - Hand Examination - OSCE Guide
Rheumatoid Arthritis
Osteoarthritis

Citation


  • Radial nerve can be assessed by touching the dorsal side of the hand between the thumb and index finger
Interphalangeal joints
Bouchard's nodes and Heberden's nodes image: From http://www.miamihandcenter.com/hand/osteoarthritis
Boutonniere's deformity image: By Alborz Fallah (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
Swan neck deformity image: By User:Phoenix119 (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
Rheumatoid arthritis image: "Arthrite rhumatoide" by Original source: http://nihseniorhealth.gov/arthritis/toc.htmlOriginally from fr.wikipedia; description page is/was here.. Licensed under Public Domain via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Arthrite_rhumatoide.jpg#/media/File:Arthrite_rhumatoide.jpg
Carpal Tunnel Syndrome image: "Untreated Carpal Tunnel Syndrome" by Dr. Harry Gouvas, MD, PhD. Original uploader was Harrygouvas at en.wikipedia - Transferred from en.wikipedia; transferred to Commons by User:Common Good using CommonsHelper.(Original text : I Dr. Harry Gouvas, MD, PhD created this work entirely by myself.). Licensed under Public Domain via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Untreated_Carpal_Tunnel_Syndrome.JPG#/media/File:Untreated_Carpal_Tunnel_Syndrome.JPG
Rheumatoid nodules image: From http://jointpainanswer.com/book/export/html/32
Onycholysis image: Onycholysis image: By CopperKettle (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
Radial Pulse image: "Radial pulse". Licensed under Public Domain via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Radial_pulse.jpg#/media/File:Radial_pulse.jpg
Hand nerves image: By yourcity.md from http://www.facthut.com/carpal-tunnel-median-nerve-distribution-hands/eW91cmNpdHkqbWR8QkxPR1N8aW1hZ2UqYXhkfnBpY3R1cmU9MjAxMXwxfENUUypqcGc_eW91cmNpdHkqbWR8QmxvZ3N8cG9zdHwyMDExfDAxfDA2fENhcnBhbC1UdW5uZWwtU3luZHJvbWUqYXNweA/


http://www.miamihandcenter.com/hand/osteoarthritisnormal range in 90⁰