1. James Pegrum (Peggers) MB BS BSc MSc MRCS Diploma (IKAR,IUAA,ISMM)

2. Overview Hand Anatomy Hand Examination Wrist & Arm X Rays

3. Hand Anatomy

4. Hand Anatomy – carpal bones “Some Loves Try Positions That They Can’t Handle”

5. Hand Anatomy – Carpal Tunnel Draw the carpal tunnel incision on each other

6. Hand Examination Overview Look Systemically Look Locally Feel Move Special Tests Function

7. look Systemically

8. Look Locally Finger Nails Clubbing Pitting Onycholysis Dorsum Guttering Bruising Scars Palmar Dupytrens Thenar wasting Scars Joints Heberdens nodes DIP Bourchard’s nodes PIP Deformity

9. Look Locally

10. Look

13. OA vs RA OARA SkinNMay be thin bruised – steriods Erythema Soft tissuesWasting of musclesMuscle wasating Synovitis around joints Warm & Tender BoneDIPJBilateral diffuse PIPJ DefomitySquaring of the palm Joint subluxation DIPJ Ulnar deviation fingers Radial deviation wrist Z deformity of thumb Swan neck & boutonierre

14. Look – Nails

15. Look

16. Peggers Top Tip A Rheumatoid patient what you need to tell the examiner……… Active or inactive disease? How do you tell? If the patient is rheumatoid factor positive? How do you tell?

17. Look

19. Peggers Top Tip When looking for a tendon injury place elbows on table/knee wrists flexed and finger pointing to each other………. Simple ask patient to extend the wrist and watch for the cascade

20. Look

22. Feel Tenderness Temperture Swelling Bogginess

23. Move Finger cascade Precision Grip Fist and note strength Supination / Pronation

24. Special Tests Carpal Tunnel De Quervain’s Flexor Tendons Neurological

25. Carpal Tunnel Tinels’ Tap Test Phalens Test

26. De Quervain’s Tests for tenosynovitis / Tendinopathy

27. Flexor Tendons FDP FDS

28. Neurological – Median Nerve Look Thenar muscle wasting Carpal tunnel scar Wrist laceration from self harm Feel Radial 3 ½ fingers Test “O Sign” thumb and Index finger

29. Neurological – Ulnar Nerve Look Hypothenar muscle wasting Wrist and elbow scars Feel Ulnar 1 ½ fingers Test Abduct and adduct fingers

30. Neurological – Radial Nerve Look Wrist drop Scars around humerus Feel Dorsal 1 st web space Test Wrist extension – “stop sign” Thumbs up

31. Functions – Day to day living Hold pen and write Keys Buttons on Shirts Stand from sitting

32. Summary Systemic Features Face Look Nails, Dorsum, Palmar, Joints Feel Tenderness, Swelling, Temperature, Bogginess Move Finger cascade, Precision, Fist, Supination/Pronation Special Tests Carpal tunnel, De Quervain’s, Flexors, Neurological Functions Pen, Keys, Buttons, Standing

33. X - Rays

34. Common Fractures

36. What you have learnt Hand Anatomy Hand Examination Common X Rays

37. Thank you This lecture and teaching materials can be found on the following website www. peggers super summaries. com (all 1 word) www.peggerssupersummaries.com