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 5 th digit Radial:1 st 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*

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/extension PIP: N flexion of PIP = FDS intact DIP: 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

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