1. Examination of the hand
C.Snyckers

2. 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.

3. 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

4. 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

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

6. Surface anatomy
Sensory supply

7. 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.

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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

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

19. The end