Principles of examination of the hand in primary care

1. Hand examination in primary care
Ian Grant
Consultant Plastic Surgeon
Addenbrooke’s Hospital
Cambridge
2010

2. Examination
Begins when the patient enters the
room

3. Examination: sequence
Look
Feel
Move
Provoke
Quantify

4. Look
 Surface anatomy
 Posture: cascade
 Deformity, swelling, skin quality

5. Ulnar nerve palsy – first web wasting, small and ring
finger MCP hyperextension, PIP joint flexion

6. Thenar wasting
Carpal tunnel syndrome

7. Posture: Boutonnière deformity – central
slip avulsion - division
IGIG
IG
IG IG IG

8. Posture: extended digit
FDP avulsion ring finger - rugby shorts
IGIG
IG

9. Posture: extended digit
FDP rupture - bricklayer
IGIG
IG
IG
IG

10. Deformity:
Dupuytren’s disease
(cords, pits, nodules)

11. Rheumatoid arthritis - posture /
deformity

12. Thumb OA – posture, CMC
subluxation

13. Palpate
 Skin quality and temperature
 Tenderness: radial to ulnar,
proximal to distal, dorsal then volar
 Leave likely tender areas to last

14. Move: active then passive
 Wrist Flex
70
Radial
15
Pronation
85
Extend
50
Ulnar
30
Supination
85

15. Move
 Fingers
Joint Motion
MCPJ 0-90º
PIPJ 0-110º
PIPJ 0-70º
Total 270º

16. Neurological examination
 Sensibility
 Sensation: static 2 point discrimination
 Ten test – compare 2 sides 10/10 –
light moving touch

17. Grip and strength
 Muscle grade MRC 0-5
 0= no contraction
 1= Trace of contraction
 2= Muscle contraction but not against gravity
 3= Move limb against gravity
 4= good but not normal
 5= Normal

18. Grips
 Power (all 4 fingers)
 Pinch (tip to tip)
 Key (thumb pulp)
 Tripod (three fingers)
 Karapandji - opposition
testing (the patient touched
the tip of the thumb to the
index, middle, ring and small
finger tips -

19. Vascular
 Capillary refill
 Allen’s test

20. Bone / Joints
 Swelling, deformity, loss of motion
 Gamekeeper’s / Skier’s thumb
 Mallet finger
 Scaphoid fracture vs Scapho-lunate
ligament rupture

21. Provocation tests
 DeQuervains: Finkelstein’s test
 Phalen’s
 Tinel’s
 Watson’s test, pivot shift test, scapholunate
ballotment test, Reagan’s test for luno-triquetral
instability
 CMC joint pressure/Radial and ulnar deviation