Examination of the hand

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Examination of the hand

• C.Snyckers

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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.

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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

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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

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Surface anatomy

• Remember traditional terms (posterior, medial
  etc.) replaced by
• Volar
• Dorsal
• Ulnar
• radial

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Surface anatomy

• Sensory supply

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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.

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Surface anatomy- dorsum

• Digits
• Digits are straight with two areas of transverse
  wrinkles marking the IPJ
• Check for
• Heberdens nodes (OA) DIPJ
• Bouchards nodes (OA) PIPJ
• Mucous cysts
• Erythema
• Swelling (fusiform, eccentric)

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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

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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 Listers 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

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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
  Dupuytrens
• 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

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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

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Finger deformities

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

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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

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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

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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

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Special tests

• Froments test and sign ulnar nerve lesion
• Phalens test and Tinels test and sign
• carpal tunnel

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• Finkelstein test de Quervains
• Allens test vascular supply of the hand

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The end