Objectives

Evaluation of the Hand for

the Non-Specialized
Clinician
Cuong Pho,
Pho, DPT,OCS,SCS,CHT,ATC
Assistant Director
Kaiser Permanente Southern California
Hand Therapy Fellowship Program
Email: cuong.x.pho@kp.org
„ Relate anatomy and pathology of the hand to
examination procedures.
Utilize evidence-
evidence-based examination techniques
„
to interpret signs and symptoms in the hand.
„ Decide what, if any, grip consistency tests
should be used in the clinic.
„ Identify the offending tissues producing ROM
limitations.

History
„ Identify Problems/Concerns

Systems Review
„ Obtain Symptom History

„ Level of pain

Nail Appearance Skin Appearance

„ Color „ Atrophy

„ Texture „ Callouses

„ Shape „ Sudomotor

„ Trophic changes

„ Wound, scar, edema

1
 Examination of Sympathetic
Function
„ Vasomotor
„ Skin color: flushed / rosy -> pallor / cyanotic (cool phase)

„
„ Skin temperature: warm -> cool
Sudomotor Tests and Measures
„ Sweat: dry skin -> dry or overly moist
„ Pilomotor
„ Gooseflesh response: absent
„ Trophic
„ Skin texture: thin, smooth > shiny, smooth, nonelastic
„ Soft-
Soft-tissue atrophy: pronounced in finger pulps
„ Nail changes: blemishes -> talonlike
„ Hair growth: fall out, longer, fine
„ Rate of healing: slowed

Resting Attitude / Posturing Anomalies / Deformities

Anomalies / Deformities Anthropmetric Measurements

„ Volumetric

„ Figure 8

„ Circumferential

2
 Range of Motion Range-of-Motion
„ Wrist „ Fixed units
„ Flexion & Extension „ 2nd and 3rd metacarpals
„ Radial & Ulnar Deviation „ Distal carpal row
„ Finger MCP / PIP / DIP Flexion & Extension
„ Thumb MCP / IP Flexion & Extension
„ Thumb CMC Abduction & Adduction „ Mobile units
„ Thumb ray
„ Thumb Opposition
„ Index finger
„ Flexion → Distal Palmar Crest „ MF, RF, SF w/ 4th/5th
metacarpals

Muscle Performance Flexors

„ FPL
„ Extrinsic: origin in the forearm and tendinous
insertions in the hand - video
„ Flexors: on volar side; flex digits/wrist „ FDP
„ Extensors: on dorsal side; extend digits/wrist
„ Intrinsic: originate / insert in the hand „ FDS
„ Thenar
„ Hypothenar „ FCR
„ Interossei:
Interossei:
„ Flex the MP joints
„ Extend IP joints „ FCU

„ Palmaris longus

Extensors retinaculum
Flexor Muscles
compartments
„ Primary finger flexors:
„ FPL „ 1st: APL, EPB
„ FDP
„ FDS

„ 2nd: ECRL, ECRB

„ Primary wrist flexors:
„ FCR / FCU
EPB
„ Palmaris longus
„ 3rd: EPL

3
 Extensors retinaculum
Extensor Muscles
compartments
„ Primary wrist extensors
„ 4th: EI, EDC „ ECRL
„ ECRB
„ ECU

„ 5th: EDM
„ Primary finger extensors
„ EDC
EPB
„ EI
„ 6th: ECU „ EDM
„ EPL

Muscle length Intrinsic Muscles

„ Intrinsic tightness test (Bunnell
(Bunnell / Littler)
„ APB

„ FPB

„ Extrinsic tightness test „ OP

„ AP

Intrinsic Muscles Intrinsic Muscles

„ ADM

„ FDM

„ Dorsal interossei

„ ODM
„ Palmar interossei

„ Lumbricals

4
 Clinical Signs Resting Attitude / Posturing
Signs Presentations „ Intrinsic-
Intrinsic-plus position
Froment’
Froment’s
Reverse Froment’
Froment’s
Jeanne’
Jeanne’s „ Intrinsic-
Intrinsic-minus hand
Wartenberg’
Wartenberg’s
Egawa’
Egawa’s

Grip Strength Testing Pinch Strength Testing

Sensibility Sensibility

5
 Clinical Tests of Sensibility Primary Sensory Modalities
„ Threshold tests „ Light touch
„ Determine minimum stimulus that can be perceived „ Pinprick
„ Objective tests „ Temperature
„ Determine how many nerve endings fire at the same „ Deep pressure
time
„ Vibration
„ Functional sensation tests
„ Propioception or joint position
„ Determine the quality of sensibility
„ Provocative tests

Complex Sensory Functions Sensory Return

„ 2-point discrimination „ Pain/temp - Pinprick, temperature
„ Moving and static „ Vibration 30cps - Tuning fork 30cps
„ Graphesthesia „ Moving touch - Moving light touch
„ Ability to identify a number traced on the skin of the palm of
the hand despite normal cutaneous sensation
„ Constant touch - Semmes Weinstein
„ Stereognosis „ Vibration 256cps - Tuning fork 256cps
„ Ability to distinguish between various shapes or textures by „ Touch localization - Touch localization
touch „ 2 pt discrimination - 2 pt discrimination
„ Barognosis „ Stereognosis - Stereognosis
„ Ability to distinguish between different weights

Light Touch testing Pain sensation testing

„ Respond “yes”
yes” when stimulus is detected „ Use a clean, unused safety pin (dispose after use)
„ Touch single spot but do not drag cotton „ Respond “sharp”
sharp” or “dull”
dull” when stimulus is
„ Vary timing and location detected
„ If delayed or no response, alternate between intact area „ Apply stimulus in a random order and with
and ask if feels the same variable speed
„ Can also check for ability to localize stimulus & moving „ Use equal force with sharp and dull end (enough
„ Map out impaired area to indent but not break skin)
„ Describe as intact, impaired, absent or hyperesthesia on
body chart

6
 Pain sensation testing
„ Apply to one peripheral nerve or dermatome
distribution at a time (min 5 stimuli per area)
„ Once an impaired area has been found apply
only the sharp stimulus in order to map out the
boundaries
„ May also apply stimulus from proximal to distal
to detect distal stocking-
stocking-glove distribution of
sensory loss in symmetric polyneuropathy
Pain sensation testing
„ Map out impaired area
„ Describe as intact, reduced, absent or
hyperesthesia (record number of accurate
responses in impaired areas)
„ Example: Sharp/dull discrimination was
reduced (3/5) in the axillary nerve distribution.
Temperature
„ Useful when differentiating specific nerve fibers
in peripheral nerve disorder
„ Otherwise pain testing sufficient
„ Map out impaired area
„ Describe as intact, reduced or absent
„ Example: Thermal sensation is absent in all 4
extremities in a stocking-
stocking-glove distribution.
Pain sensation testing
„ Sensation may be absent to both sharp and dull
stimuli (light touch and pain absent)
„ Sharp stimuli might be perceived as dull (pain
perception absent or hypoalgesia)
hypoalgesia)
„ Pinprick might be perceived as sharper or more
noxious in certain areas (hyperalgesia
(hyperalgesia))
„ Pain or noxious response to blunt end or non-
non-
noxious stimuli (allodynia
(allodynia))
Temperature
„ Respond “cold”
cold” or “hot”
hot” to stimulus
„ Make sure outside of test-
test-tube is dry
„ Hot water should not exceed 45 deg C
„ Allow min of 2 seconds for each contact
Use forced-
„ forced-choice procedure
„ Test one nerve distribution at a time
Vibration
„ Strike the top of the tuning fork to begin the
vibration
„ Hold the tuning fork by the stem
„ Apply the stem to skin or bony prominence
„ Vibration vs pressure
„ Describe as intact, reduced or absent
7
 Vibration Two-Point Discrimination
„ Test distal to proximal „ Respond “one”
one” or “two”
two” to the stimulus
„ Test first over cutaneous areas in nerve „ Alternate 1 and 2 point stimuli in random order
distribution
„ Forced-
Forced-choice method
„ Test over bony prominences if impaired or
absent in cutaneous areas test „ Start with 2-
2-points 5mm apart and widen if
patient is not able to distinguish points
„ Sensation is reduced
„ intact over bone
„ not intact over corresponding cutaneous area

Semmes-Weinstein
Two-Point Discrimination
Monofilaments
„ Normal „ Respond “yes”
yes” when stimulus is felt
„ Static: 0-
0-5mm „ Apply filament perpendicular to skin
„ Moving: 2mm
„ Sustain pressure for 1-
1-2 seconds
„ Static
„ Normal < 6mm „ Start with green filament (normal)
„ Fair 6-
6-10mm „ Move from distal to proximal
„ Poor 11-
11-15mm „ Continue with progressively thicker filaments in
„ Protective: one point perceived areas where unable to detect stimulus
„ Anesthetic: no points perceived

Semmes-Weinstein Semmes-Weinstein
Monofilaments Monofilaments
Color Sensibility Thickness
„ Full kit has 20 monfilaments
„ Highest numbered filament in each color group
Green Normal 1.65-
1.65-2.83
is all that is necessary to report functional level
Blue Diminished light touch 3.22-
3.22-3.61
„ These 5 monofilaments are available in mini-
mini-kit
Purple Diminished protective 3.84-
3.84-4.31
sensation „ Use color pen to map out body-body-chart
Red Loss of protective 4.56-
4.56-6.65
sensation
Red-
Red-lined Untestable >6.65

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 Circulatory Provocative Tests
„ Allen’
Allen’s test „ Finkelstein’
Finkelstein’s Test
„ Radial artery: gives rise to the deep arch „ Grind Test
„ Ulnar artery: gives rise to the superficial palmar
„ Collateral ligament stress
arch -> gives rise to 4 common digital arteries,
which then branch to form the proper digital „ Phalen’
Phalen’s Test / Reverse Phalen’
Phalen’s Test
arteries „ Tinel’
Tinel’s Test (Sign)
„ Median Nerve Compression Test

References
„ Hoppenfield S. Physical Examination of the Spine &
Extremities, Norwalk, CT: Appleton & Lange; 1976:
59-
59-104.
„ Hunter J, et al. Rehabilitation of the Hand and Upper
Extremity, 5th Edition, St. Louis, MI: Mosby,
Mosby, Inc; 2002:
120-
120-142,169-
142,169-182,194-
182,194-213.
„ Neumann D. Kinesiology of the Musculoskeletal
System: Foundations for Physical Rehabilitation, St.
Louis, MI: Mosby,
Mosby, Inc; 2002:172-
2002:172-241.
„ McGrouther and Colditz:
Colditz: Interactive Hand Therapy
Edition, Primal Pictures Ltd;1998.