Examination of the hand C.Snyckers

The hand Without the human hand the most refined creations of the human mind would be mere theoretical concepts. The hand is the focal point of human beings’ interactions with the environment.

General hand functions 45% of work done by the hand – grasp Power function that require both intrinsic and extrinsic coordination. 45% of work done by the hand – pinch Key pinch Tip pinch Chuck pinch 5% of work done by the hand – hook 5% of work done by hand - paperweight

Remember-The hand does not exist in isolation!!! Shoulder and elbow position hand in space. Brain and c-spine relay neurological messages to the hand. The hand is at one peripheral point of the vascular system with end-arteries ‘Pre-flight’ check helpful prior to examining the hand

Surface anatomy Remember – traditional terms (posterior, medial etc.) replaced by: Volar Dorsal Ulnar radial

Surface anatomy Sensory supply

Surface anatomy- dorsum Dorsal aspect: Fingernails Alignment – point toward tubercle of scaphoid when flexed smooth eponychium (cuticle) Pink nailbed Crescent lunula Many deformities of systemic or local origin Paronychium, subungual heamatoma Psoriatic pitting, splinter hemorrhages etc.

Surface anatomy- dorsum Digits Digits are straight with two areas of transverse wrinkles marking the IPJ Check for Heberden’s nodes (OA) DIPJ Bouchard’s nodes (OA) PIPJ Mucous cysts Erythema Swelling (fusiform, eccentric)

Surface anatomy-dorsum Hand Dorsal skin loose Extensor tendons visible 1st dorsal interosseos most prominent muscle mass on dorsum – atrophy with ulnar nerve injury Check for Tendonitis, swellings – rheumatoid arthritis ‘Dropped knuckle’ – trauma Bossing – metacarpal base II

Surface anatomy-dorsum Wrist Head of ulna – pro / supination and DRUJ TFCC- hollow just distal to head of ulna 6 extensor tunnels Extensor carpi ulnaris, extensor digiti minimi Extensor digiti communis Extensor pollicus longus – Lister’s tubercle Extensor carpi radialis brevis, longus Abductor pollicus longus, extensor pollicus brevis Snuffbox – scaphoid Mid wrist – scapho-lunate joint Check for Tenderness, ganglia, tendinitis, tendon ruptures

Surface anatomy-volar Hand - normal resting arcade of fingers Flexion finger creases – joints Palmar skin tightly adhered for grip (palmar aponeurosis) Distal & proximal palmar creases Thenar/ hypothenar eminences Check – Fingertip abscess - felon Loss of creases and tightness – infection Contracture of the palmar aponeurosis – Dupuytren’s Cardinal signs of Kanavel – septic tenosynovitis Fusiform finger swelling Finger held in flexed position Painful passive extension Tenderness over the palmar surface along the tendon

Surface anatomy-volar Wrist Distal wrist flexion crease – proximal border of the flexor retinaculum ( Carpal tunnel) Radial artery between flexor carpi radialis and abductor pollicus longus Oppose thumb and little finger – palmaris longus (80% of people) Between palmaris longus and flexor carpi radialis – median nerve Ulnar side – pisiform bone – flexor carpi ulnaris Ulnar artery – radial to the flexor carpi ulnaris Check Synovitis – rhumatoid arthritis Ganglion - common

Finger deformities Mallet finger DIPJ remains in flexion – ext tendon rupture Rheumatoid arthritis Boutonniere Flexion PIPJ with extension DIPJ – central slip tear Swan neck deformity Flexion DIPJ with extension PIPJ – Old mallet finger

Hand deformities Ulnar claw hand – ulnar nerve lesion MCP hyperextention flexed PIPJ of little and ring Benedictine hand – median nerve lesion Poor middle and no index MPJ and PIPJ active flexion Claw hand – median and ulnar lesion Hooked claw of all fingers with MPJ extension

Range of motion - compare Wrist Dorsiflexion: 60°-70° Plantarflexion: 60°-80° Radial deviation: 20° Ulnar deviation :30°- 40° Also check – tenodesis effect wrist flexion should passively extends fingers – extensor tendon injury Wrist extension should passively flex fingers – flexor tendon injury

Muscle testing Abductor pollicus brevis – median nerve function 1st dorsal interosseos – ulnar nerve function Finger ab/adduction - unlar nerve function Thumb PIPJ flexion for anterior interosseos function MPJ extension – radial nerve function

Special tests Froment’s test and sign – ulnar nerve lesion Phalen’s test and Tinel’s test and sign – carpal tunnel

Finkelstein test – de Quervain’s Allen’s test – vascular supply of the hand

The end