Examination of the Hand

Introduction

• Introduce yourself to the patient
• Wash your hands
• Briefly explain to the patient what the examination involves
• Ask the patients to place their hands on a pillow

Always start with inspection and proceed as below unless instructed otherwise; be prepared to be instructed to move on quickly to certain sections by the examiner.

Inspection

Ask the patient to pronate their hands

• Inspect for pathology in the:
  • Nails
  • Heberdens (DIPJ) or Bouchards (PIPJ) nodes (present in osteoarthritis)
  • Dorsum of the hand
• Check the rotational axis of each finger (look from the tips of the fingers) to assess for any rotational deformity

Ask the patient to supinate their hands

• Assess for any obvious pathology in the palms (e.g. Dupuytren’s contractures)

Ask the patient to flex their elbows and show you their elbows / dorsal surface of their forearms

• Check for psoriatic plaques, rheumatoid nodules, or gouty tophi

Palpation

Ask the patient to again place their hands back on the pillow, in a supine position:

• Assess temperature
  • Using the dorsal surface of your own hand, feel distal to proximal along the patient’s hand and forearm, and compare with the contralateral side
• Feel for the radial pulse
• Assess the muscle bulk of the thenar eminence and hypothenar eminence
  • Run the pad of your thumb firmly over these areas
  • Compare for asymmetry, caused commonly by disuse or denervation (i.e. carpal tunnel syndrome)
• Assess the tendons of the hand, feeling for nodules or contractures
  • Assess again by running down with the pad of your thumb

Ask the patient to pronate their hands:

• Palpate the bony anatomy of the hands, feeling for any tenderness
  • The radial and ulnar styloid processes
  • The carpal bones
  • Along the length of each metacarpal
• Gently squeeze all 4 MCP joints together (often painful in inflammatory arthropathies)
• Bimanually palpate all of the MCP joints, PIP joints, and DIP joints
  • This is best done by placing the thumb and index finger around the joint in a pincer like grip, and the other hand the same at 90^o to the first hand, feeling for tenderness and laxity in the joint

Movement

Ask the patient to keep the hands in the pronated position:

• Check the extensors of the hand, asking the patient to
  • Extend the wrist against resistance (extensors)
  • Raise the thumb off of the pillow (EPL)
  • Hold the wrist passively in extension and ask the patient to extend their fingers (ED)
  • Flex the fingers to 90^oat the MCP joints and ask the patient to extend their fingers again (lumbricals)

Ask the patient to supinate the hands:

• Check the flexors of the hand, asking the patient to
  • Flex the wrist against resistance
  • Flex the fingers at the PIP joints
    • Isolate the 3 fingers that are not being tested (simply hold them in the natural anatomical position) and ask the patient to flex the finger being tested (FDS)
  • Flex the fingers at the DIP joints
    • Isolate the proximal and middle phalanges by holding them firmly and then asking the patient to flex the distal phalynx of that finger (FDP)
  • Check the action of the wrists, asking the patient
    • Abduct their wrists against resistance
    • Adduct their wrists against resistance
  • Check the action of the thumbs, asking the patient to
    • Flex the thumb (FPL)
    • Abduction the thumb (APL and APB)
    • Adduction the thumb (AP)
    • Opposition the thumb (OP)

Assess the functioning of the hand by assessing:

• Power grip
  • Place two fingers in to the patient’s palm and ask them to squeeze as firmly as possible
• Pincer grip
  • Ask the patient to pinch the tip of you finger
• Fine motor function
  • Ask the patient to pick up a penny or do up the buttons on a shirt

Check the sensorimotor function of the terminal branches of the brachial plexus*:

• Median nerve
  • Motor – confirm thumb abduction is present (tests APB)
  • Sensation – check at the radial border of tip of index finger
• Radial nerve
  • Motor – confirm MCPJ extension is present (tests ED)
  • Sensation – check at the dorsal surface of first digital web space
• Ulnar nerve
  • Motor – confirm finger abduction & adduction (tests palmar and dorsal interossei)
  • Sensation – check at the ulnar border of tip of little finger

Assess the vascular status of the hand by assessing:

• Colour / temperature / capillary refill time

*In the context of trauma, a different assessment is performed, assessing each aspect of the brachial plexus in turn

Special Tests

• Phalen’s Test (test for carpal tunnel syndrome)
  • Ask the patient to place the dorsal surfaces of their hands together and then fully flex the wrists (the ‘reverse prayer’). Hold for 30–60 seconds. This will reproduce their symptoms in positive cases
• Tinel’s Test (test for carpal tunnel syndrome)
  • Gently percuss over the volar aspect of the carpal tunnel – this is found just distal to the wrist crease, overlying the carpal bones. In a positive test, the patient will report paraesthesia in the distribution of the median nerve
• Finkelstein’s Test (test for DeQuervain’s Tenosynovitis)
  • The thumb is flexed across the palm and the fingers are then wrapped around it. The wrist is then passively adducted (or ulnar deviated). This causes a disproportionate amount of pain over the radial styloid on the affected side

Complete the Examination

Thank the patient once completed. Remember, if you have forgotten something important, you can go back and complete this.

State to the examiner that to complete your examination you would also like to examine the joint above (the elbow), the contralateral hand, and reviewing any relevant imaging available.