hand examination in primary care

Hand examination in primary care

Ian GrantConsultant Plastic Surgeon

Addenbrooke’s Hospital Cambridge

2010

ExaminationBegins when the patient enters the room

Examination: sequence

LookFeelMoveProvokeQuantify

Look

Surface anatomy Posture: cascade Deformity, swelling, skin quality

Ulnar nerve palsy – first web wasting, small and ring finger MCP hyperextension, PIP joint flexion

Thenar wasting

Carpal tunnel syndrome

Posture: Boutonnière deformity – central slip avulsion - division

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Posture: extended digitFDP avulsion ring finger - rugby shorts

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Posture: extended digitFDP rupture - bricklayer

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Deformity:Dupuytren’s disease(cords, pits, nodules)

Rheumatoid arthritis - posture / deformity

Thumb OA – posture, CMC subluxation

Palpate

Skin quality and temperature

Tenderness: radial to ulnar, proximal to distal, dorsal then volar

Leave likely tender areas to last

Move: active then passive

Wrist Flex70

Radial 15

Pronation85

Extend50

Ulnar 30

Supination85

Move

Fingers

Joint MotionMCPJ 0-90º

PIPJ 0-110ºPIPJ 0-70ºTotal 270º

Neurological examination

Sensibility Sensation: static 2 point discrimination Ten test – compare 2 sides 10/10 –

light moving touch

Grip and strength

Muscle grade MRC 0-5 0= no contraction 1= Trace of contraction 2= Muscle contraction but not against gravity 3= Move limb against gravity 4= good but not normal 5= Normal

Grips

Power (all 4 fingers) Pinch (tip to tip) Key (thumb pulp) Tripod (three fingers) Karapandji - opposition

testing (the patient touched the tip of the thumb to the index, middle, ring and small finger tips -

Vascular

Capillary refill Allen’s test

Bone / Joints

Swelling, deformity, loss of motion Gamekeeper’s / Skier’s thumb Mallet finger Scaphoid fracture vs Scapho-lunate

ligament rupture

Provocation tests

DeQuervains: Finkelstein’s test

Phalen’s

Tinel’s

Watson’s test, pivot shift test, scapholunate ballotment test, Reagan’s test for luno-triquetral instability

CMC joint pressure/Radial and ulnar deviation