Clinical Examination of Hand

1. EXAMINATION OF HAND
Dr Avinash Rao. G (Fellow In Hand Surgery)
SKIMS

2. Hand – Complex Anatomy
 Skin (Palmar & Dorsal)
 Ligaments , Bones & Joints
 Flexor and extensor tendons
 Tendon sheath & Pulley system/ Retinaculum /
Palmar fascia
 Nerves
 Vessels
 Nail, Nailfolds and Nailbed
 Potential spaces of Hand , Webs
 Intrinsic & Extrinsic muscles

3. Disorders
 Congenital / Devolopmental
 Traumatic
 Infective
 Inflamatory
 Degenerative
 Neoplastic
 Metabolic
 Vascular or Neuropathic Disorders
 Idiopathic / Genetic
 Iatrogenic

4. Contents
 Surface Anatomy , Arches & Spaces of hand
 Basic Hand functions
 Examination of Hand
1. Demographic data, detailed history and General examination.
2. Local examination
 Inspection
 Palpation -
 Movements
 Measurements
 Special tests (for arteries, tendons, nerves (motor and sensory)
and ligament instability)

5. Surface Anatomy

8. Relation of creases to the joints

18.  Hand itself is an organ
A. 45 per cent of hand function is utilized for grasp,
B. 45 per cent for pinch (key, tip, chuck pinch),
C. 5 per cent for hook function and
D. 5 per cent hand functions as a paper weight (most
primitive function)

19. Instrument Use
Stethescope Bruit
Cotton Sensation
Pin Pinch
Tuning fork Vibration
Goniometer ROM
Scale / Tape Length
Ball Grasp
Card Test
Filaments Sensory testing
Discriminator Two PD
Lint Measure & Planning
Torch Illumination
Skin Marking pen Surface Marking

20. DEMOGRAPHIC DATA
Informant & Reliabilty – Malingering / Honest.
Hand Dominance -
Name-
Age / sex –
Address –
Occupation / Education –

21. Chief Complaints
 Chronological order
 In patients own language
1. Pain
2. Swelling
3. Deformity
4. Stiffness
5. Weakness
6. Numbness
7. Clumsiness
8. Functional Limitation / Loss of power etc….,

22. History
Pain: Onset (injury/spontaneous; acute/insidious), type, location, duration,
remote injury (RSD), aggravating and relieving factors, Night pain,
Seasonal Variation.
Swelling: Onset, location, duration, relieving and aggravating factors,
flare-ups (severity, frequency, duration), previous treatment if any,
association with fever/stiffness, discolouration.

23. History
 • Deformity: Onset, Duration, Severity, abnormal contours, palm and finger
alignment, Associated with joint Laxity / Instability.
 • Loss of power: Any decreased strength or dexterity. Apart from above it
is very important to ask for history of hospitalizations and treatment (type,
response and after), details of trauma if present, dominant hand, effect on
occupational functioning and ADL.
 • Loss of function: onset , duration, progression, associated with any of the
above.

24. `
Negative History

25. `
Functional limitations

26. ADL

27. Significant
 Past history- Medical / Surgical / Drug.
 Personal History
 Family history
 Birth History / Milestones
 Socioeconomic History – Important when considering for surgery

28. General & Systemic
Examination
 Built & Nourished.
 Oriented with time / place / person.
 P I C K L E,
 Vitals – febrile / afebrile
Bp - mm hg
Pr – min
Sp02 – at room air.
 Cvs – s1 + s2 +, no Murmers.
 Rs- B/L AE +, No Adventetious Sounds.
 P/A – soft ,non tender.
 CNS – IQ / Intelligence
 Neurocutaneous Markers – NF, Leprosy etc
 Head to toe examination – Syndromic / Multisite
 Anthrapometry – Ht, Wt, BMI, Armspan, US/LS ratio, Chest expansion.
(IN RELEVANT CASES)

29. Local Examination
 1) INSPECTION (Look) – (keep the hand on a pillow with whole
ipsilateral and contralateral upper limb exposed):
 Attitude / Alignment
 Deformity – Clawing / Mallet/ Boutonniere / Z thumb.
 Discolouration - Pale/ Redness/ Bluish / Hyperpigmentation/ Shiny
red.
 Swelling / Thickenings / Web creeps / Nodules / Cords.
 Wasting of Muscles
 Scars / Sinuses
 Nail Changes / Trophic changes / Length discrepency / Number of

30. Attitude / Alignment –
 Axial alignment – Whether viewed from dorsal or volar aspect with fingers
and thumb in adduction – the forearm, wrist and hand (middle finger)
should be in a straight line .
 Ulnar deviation of MCP joint and radial deviation of wrist are
observed in rheumatoid arthritis (RA).
 Sagittal Malalignment –
I. Dislocation of PIP joint is visible as a step off
II. Rupture of extensor slip in RA produces flexion deformity of fingers at
MCP joint.

31.  Rotational malalignment
– Ask patient to flex fully each finger in turn – the fingers should unfailingly
point towards the scaphoid tuberosity in increasing degree of flexion
from index to little.
– Ask patient to partially flex the fingers together at MCP joint – nails of
index finger and those of ring and little finger face away from that of
long finger in supinated hand.

32. Finger Cascade

34. Dorsal aspect:
 • Nails: vasculitic changes - splinter haemorrhage, periungal
telengiactases (SLE, scleroderma), pin-size pitting (psoriasis),
hyperkeratosis, onycolysis, discolouration, ridges, anaemia, dilated
capillary loops over nail fold, paronychia, subungal haematoma.

35.  • Fingers (examine from DIP to MCP):
Mallet finger (avulsion of EDC, EPL for thumb), redness, nicotine stain,
sausage shaped digits, arthritis mutilans, tophi, swan neck /
boutonniere deformity, Z-deformity of thumb, Bouchard’s nodes,
Heberden nodes, Garrod pads, ulnar deviation, benediction attitude,
clawing of fingers, contractures, telengiectasia, mucous cyst, inclusion
cyst, sebaceous cyst, skin and appendages
Dorsal aspect:

36.  Hand: Dropped knuckle (# metacarpal), fore-shortening of
metacarpal, wasting in first web space, wasting of interossei, skin and
appendages, carpal bossing.
 Wrist: Head of ulna (prominent in pronation disappears in
supination), dinner fork deformity, ulnar deviation, volar subluxation,
volar-ulnar subluxation, cystic swelling (ganglion).
Dorsal aspect:

37. Radial aspect
 Thumb and 1st MCP joint (basilar joint): (Skier’s thumb or
gamekeeper’s thumb), swelling (1st MCP arthritis).
 • Wrist: Anatomical snuffbox (bound dorsally by EPL and volarly by APL
and EPB) for swelling.

38. Volar aspect:
 Fingers and palms:
Pulp spaces for pits (Raynaud’s phenomenon) and swelling (Felon),
swelling over volar aspect of finger (GCT tendon sheath or cystic
swelling / enchondromas), jersey finger (avulsion of FDP), flexion
cascade of fingers, Arches of palm, palmar skin for pits and cords/
nodules (Dupuytren’s contracture), signs of flexor tendon sheath
infection - (Kanavel’s signs – fusiform swelling extending along MP and PP into
distal palm + tenderness along volar aspect + finger held in flexed position +
passive extension causes pain),
 Thenar and mid palmar spaces - infection,
 Thenar and hypothenar wasting.

39.  Wrist: Tendon of Palmaris longus (ask patient to touch the tips of thumb
and little finger and flex the wrist – tightens the palmar fascia and makes
tendon prominent), FCR, FCU, compound palmar ganglion.
Volar aspect:

40. Ulnar aspect:
 Hypothenar wasting, head of ulna (capita ulna syndrome – in
RA the volar subluxation of carpals and dorsal subluxation of ulnar
head accentuates the deformity with prominent head of ulna).

41. 2) Palpation –
 Local Rise of Temperature – Infective / Inflamation
 Bony / ST Tenderness – Localise
 All the inspectory findings confirmed.
 Tactile Adhesion test
 Sequential palpation – nontender first.
 Vascular tests
 Motor examination
 Sensory examination
 Special tests

42. Dorsal aspect
 Nail and paronychial folds – capillary refill
 Fingers: for mallet finger, collateral ligaments especially for thumb, joint
swelling and effusion, MCP joint for collateral ligament tenderness.
 Metacarpals for deformity, tenderness, first metacarpal base for
Bennett’s fracture / Rolondo fracture. Instabilty of CMCJ.

43. Dorsal aspect
 Wrist
Radial styloid, De Quervain’s disease (tenovaginitis of 1st dorsal
compartment – APL, EPB), lister tubercle (2 cm ulnar to radial styloid),
anatomic snuff box (for dorsal branch of radial artery, # scaphoid, 3-4
mm distal to it is basilar joint), 2nd dorsal compartment (ECRL, ECRB,
intersection syndrome, ganglion is most likely to occur here), 4th dorsal
compartment (EDC tendons in RA), TFCC just distal to ulnar styloid.

44. Palmar aspect
 As in inspection confirm the findings of felon, flexor sheath infection,
mid-palmar space, thenar space.
 Swelling of ganglion, GCT tendon sheath, triggering.
 Tubercle of scaphoid, hook of hamate, pisiform, pisiohamate ligament
and Guyon’s canal, FCR, median nerve (between Pl and FCR), volar
carpal ligament (proximal limit corresponds with the distal radial
crease).

45. Capillary refill time

49. Tactile adherence test – Autonomic
Dysfunction

50. Movements –

52. Movements –

58. Measurements –

59. JAMAR
VOLUMETER

62. Grip & Pinch Strength
measurement

63. SPECIAL TESTS
 Vascular tests
 Tests for tendons
 Test for nerves
 Tests for ligament instability

64. Vascular tests
 Allens test
 Digital Allens test
 Capillary refill test
 Adson’s test
 Wright’s test
 Roos test

65. Allen’ test

66. Digital Allen’s test

67. Adsons test

68. Wright’s test

69. Roos Arm Elevation test

70. Special tests – for Tendon
Muckard test finkelstein test Eichoffs test

71. Linburg’s test

72. Bunnell – Littler test / Finochietto Bunnel
Test / Intrinsic tightness test
 Passively flex the IP joint with MCP in extension followed by MCP in flexion.
Restriction due to intrinsic muscle tightness will increase the passive flexion
at IP joint with MCP flexion due to relaxation of intrinsic muscles.
 In extrinsic tightness the flexion decreases due to tightening of structures
with MCP flexion hence restricting flexion further.

74. Mallet Finger and Swan neck
deformity

75. Distal Bouviers test
 A “distal Bouvier-type maneuver” - utilized to distinguish a
lax PIP source of DIP flexion from a swan neck deformity
secondary to a chronic (possibly untreated) mallet finger.

76. Boutonniere deformity

77. Test for Dupuyterans contracture
Heuston table top test

78. Special tests for nerves

79. Ape thumb

80. O test – AIN palsy

81. Oschner clasping test / Pointing index / benediction
attitude
(HMNI)

82. Bottle test (APB palsy)

83. Pen Test (APB palsy)

84. TINEL’S SIGN (NERVE
PERCUSSION)

87. Reverse Phalen’s test

88. Carpal tunnel compression test / Durcan’s
Test
The examiner applies direct pressure to the carpal tunnel
with his or her thumb for upto 1minute or until onset of
symptoms.
A positive test consists of the onset of numbness or
paresthesia in the median nerve distribution.
More specific (90%) and more sensitive (87%) than either the
Tinel or Phalen test.

89. Claw Hand

90. Ulnar paradox

91. Froments sign

92. Card test

93. Watenberg sign

94. Pitres testut sign

95. Jeannes sign – Key pinch – Add Pollicis
palsy.

96. Duchenne sign

97. Bouviers maneuvers

98. Andre Thomas test

99. Semmes-Weinstein
monofilaments

100. Semmes-Weinstein
monofilaments
 Monofilament evaluator size was started from 2.83 to 6.65.
 2.83 – Green – Normal
 3.61 – Blue – Diminished light touch
 4.32 – Purple – Diminished protective
sensation
 4.56 – Red – Loss of protective
sensation

101. Two-point discrimination

102. Two-point discrimination
 STATIC
• Determine minimal separation of two distinct points when applied to palmar
fingertip
• Innervation density of slow-adapting fibers
 DYNAMIC
• As above, with movement of the points
• Innervation density of fast-adapting fibers
• Recovers earlier (6 months prior) than static 2PD.
• Value of 8-10mm less than static 2PD

104. Tests for Ligamentous Instability
(Compare with Opposite side)
 Watson’s test
 Scapholunate Ballotment test
 Reagan’s test (Lunotriquetral Ballotment test)
 Lichtman test (Mid-carpal instability)
 Murphy’s sign
 TFCC load test
 Thumb grind test
 Thumb UCL Laxity
 Varus and valgus stress test of IPJ & MCPJ

105. Watsons test

106. Scapholunate Ballotment test

107. Reagan’s test - Lunotriquetral Ballotment
test

108. Litchman test

109. Murphys sign – Lunate dislocations

110. Thumb Grind test and Lever
test

111. TFCC Load test / Ulnar meniscal grind test

112. Piano key sign

113. Thumb UCL / Skiers thumb

114. Hand Performance Assessment
 Grip Ability Test
 Sequential Occupational Dextrity Assessment
(SODA)
 Arthritis Hand Function Test
 Jebsen Hand Function Test
 Duruoz Hand Index
 Michigan Hand Outcomes Questionnarie
 Standard DASH Score / QUICKDASH score.