Approach to the Hand Examination

Karen Booth

Topics for Discussion

• Review of Anatomy

• History

• Physical Examination

• Cases

Anatomy

• Bones/Joints

• Muscles

• Nerves

• Tendons

• Vascular

• Mechanism of injury• Timing, Pain• Motor/sensory deficits

•Constitutional symptoms

• Hand Dominance•Occupation, hobbies, ADLs

• PMHx:•Tetanus status, Allergies•Systemic disease (DM, CTD)

History

1. Bones/Joints:

•LOOK/Inspection•SEADS

•FEEL/Palpation

•MOVE/ Range of Motion•Active•Passive

Physical Examination*compare both sides*

2. Vascular:

• Colour, temperature

•Pulses

•Capillary Refill

Physical Examination*compare both sides*

3. Nerves: Sensory

•Median: pulp of index finger

•Ulnar: pulp of 5th digit

•Radial: 1st dorsal webspace

•Digital Nerves: 2 point discrimination

Physical Examination*compare both sides*

3. Nerves: Motor• Extrinsic

•Median:DIP flexion of index finger (FDP)

•Ulnar:DIP flexion of 5th finger (FDP)

•Radial: Extension of wrist/thumb (ECR/EPL)

Physical Examination*compare both sides*

3. Nerves: Motor• Intrinsic

•Median: Thumb abduction (APB)

•Ulnar: Interossei-DAB-PAD

•Radial: none!

Physical Examination*compare both sides*

3. Tendons:

• Flexor Digitorum Profundus (FDP): flex DIP

• Flexor Digitorum Superficialis (FDS): flex PIP

• Extensor Digitorum Communis (EDC): extension

Physical Examination*compare both sides*

3. Tendons:

Physical Examination*compare both sides*

MCP PIP DIP

Extensor Tendons

EDC EDC (lat bundles)

Intrinsic Muscles

Flexor Tendons

Lumbrical Muscles

FDS FDP

RFA: laceration to index finger

History:• MOI: kitchen knife, vegetables•Location: R side, palmar, distal to PIP jt•Occupation: office, Hobby: instrument•Handedness: R, dominant•PMHx: NKDA, tetanus: UTD

•no systemic disease

Case #1

Examination: Compare both sides

Bones/Joints:• Look/Feel/Move – joint above/below injury

•No swelling, painful in area •Normal PIP flexion + extension •Difficulty with flexion of DIP

Vascular:• Good colour/temperature• Normal Pulses• Normal capillary refill

Case #1: laceration to index finger

Examination: Compare both sides

Neuromuscular:•Sensory: N median, ulnar, radial, digital nerves•Motor: N intrinsic fxn

Tendons:MCP jt: N flexion/extensionPIP: N flexion of PIP = FDS intactDIP: absence of flexion of DIP

Case #1: laceration to index finger

Diagnosis:

injury to FDP of index finger

Management:• Clean area, irrigate with NS, apply sterile dressing• Antibiotic Prophylaxis, tetanus if necessary• X-Ray – r/o fracture• Plastics:

•operative primary repair of tendon within 14 days

Case #1: laceration to index finger

RFA: painful swollen joints in hands

• History:

• Physical:•Bones/Joints:

• Inspection: SEADS

• Feel:

• Move:

Case #2

Case #2 Common arthritic findings in the hand

Joint OA RA

DIP ++ Rare

PIP + ++

MCP Rare ++

Wrist Rare ++

Case #2 Common arthritic findings in the hand

•RA: • subluxation of MCP

• radial deviation of wrist

• ulnar deviation of the fingers

Common Deformities in the Hand

•Boutonniere:

• hyperextended DIP and flexed PIP

• central slip of extensor tendon insertion into middle phalanx

Common Deformities in the Hand

•Swan Neck:

• flexed DIP and hyperextended PIP

•PIP volar plate injury

Common Deformities in the Hand

•Mallet Finger:

•DIP in flexion with loss of extension

•due to damage to extensor tendon

Case #3 Common Problems in the Hand

•Trigger finger/stenosing tenosynovitis

•inflammation of synovium causing friction between flexor tendon and pully sheath

•locking of finger with flex/ext •palpable nodule over MCP•painful