Approach to the Hand Examination

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Approach to the Hand Examination
Karen Booth
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Topics for Discussion

• Review of Anatomy
• History
• Physical Examination
• Cases

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Anatomy

• Bones/Joints
• Muscles
• Nerves
• Tendons
• Vascular

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History

• Mechanism of injury
• Timing, Pain
• Motor/sensory deficits
• Constitutional symptoms
• Hand Dominance
• Occupation, hobbies, ADLs
• PMHx
• Tetanus status, Allergies
• Systemic disease (DM, CTD)

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Physical Examinationcompare both sides

• 1. Bones/Joints
• LOOK/Inspection
• SEADS
• FEEL/Palpation
• MOVE/ Range of Motion
• Active
• Passive

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Physical Examinationcompare both sides

• 2. Vascular
• Colour, temperature
• Pulses
• Capillary Refill

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Physical Examinationcompare both sides

• 3. Nerves Sensory
• Median pulp of index finger
• Ulnar pulp of 5th digit
• Radial 1st dorsal webspace
• Digital Nerves 2 point discrimination

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Physical Examinationcompare both sides

• 3. Nerves Motor
• Extrinsic
• MedianDIP flexion of index finger (FDP)
• UlnarDIP flexion of 5th finger (FDP)
• Radial Extension of wrist/thumb
• (ECR/EPL)

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Physical Examinationcompare both sides

• 3. Nerves Motor
• Intrinsic
• Median Thumb abduction (APB)
• Ulnar Interossei
• -DAB
• -PAD
• Radial none!

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Physical Examinationcompare both sides

• 3. Tendons
• Flexor Digitorum Profundus (FDP) flex DIP
• Flexor Digitorum Superficialis (FDS) flex PIP
• Extensor Digitorum Communis (EDC) extension

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Physical Examinationcompare both sides

• 3. Tendons

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Case 1

• RFA laceration to index finger
• History
• MOI kitchen knife, vegetables
• Location R side, palmar, distal to PIP jt
• Occupation office, Hobby instrument
• Handedness R, dominant
• PMHx NKDA, tetanus UTD
• no systemic disease

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Case 1 laceration to index finger

• Examination Compare both sides
• Bones/Joints
• Look/Feel/Move joint above/below injury
• No swelling, painful in area
• Normal PIP flexion extension
• Difficulty with flexion of DIP
• Vascular
• Good colour/temperature
• Normal Pulses
• Normal capillary refill

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Case 1 laceration to index finger

• Examination Compare both sides
• Neuromuscular
• Sensory N median, ulnar, radial, digital nerves
• Motor N intrinsic fxn
• Tendons
• MCP jt N flexion/extension
• PIP N flexion of PIP FDS intact
• DIP absence of flexion of DIP

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Case 1 laceration to index finger

• Diagnosis
• injury to FDP of index finger
• Management
• Clean area, irrigate with NS, apply sterile
  dressing
• Antibiotic Prophylaxis, tetanus if necessary
• X-Ray r/o fracture
• Plastics
• operative primary repair of tendon within 14 days

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Case 2

• RFA painful swollen joints in hands
• History
• Physical
• Bones/Joints
• Inspection SEADS
• Feel
• Move

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Case 2 Common arthritic findings in the hand
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Case 2 Common arthritic findings in the hand

• RA
• subluxation of MCP
• radial deviation of wrist
• ulnar deviation of the fingers

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Common Deformities in the Hand

• Boutonniere
• hyperextended DIP and flexed PIP
• central slip of extensor tendon insertion into
  middle phalanx

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Common Deformities in the Hand

• Swan Neck
• flexed DIP and hyperextended PIP
• PIP volar plate injury

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Common Deformities in the Hand

• Mallet Finger
• DIP in flexion with loss of extension
• due to damage to extensor tendon

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Case 3 Common Problems in the Hand

• Trigger finger/stenosing tenosynovitis
• inflammation of synovium causing friction between
  flexor tendon and pully sheath
• locking of finger with flex/ext
• palpable nodule over MCP
• painful