Hand Physical

Examination
 Anatomy of the Hand
a. BONEs of the Hand
b. JOINTs of the Hand
c. MUSCLEs & TENDONs of the Hand

(FDP)

)(/
(FDS)

)(

▪ Thenar Eminence muscles and their nerve supply:

1. Flexor Pollicis Brevis.
Median
nerve

2. Abductor Pollicis Brevis.

3. Opponens Pollicis.

▪ Hypothenar Eminence muscles and their nerve supply:

1. Flexor Digit Minimi.
nerve
Ulnar

2. Abductor Digit Minimi.

3. Opponens Digit Minimi.
d. BLOOD SUPPLY of the Hand
e. NERVE SUPPLY of the Hand
 Physical Examination of the Hand
Position: Sitting.

Exposure: The upper limb.

Sequence: Distal to proximal, superficial to deep (skin → subcutaneous tissue → muscles → tendon).

In ER: Stabilize the patient first then do comprehensive examination (ATLS).

In clinic: Start with hand examination.

ALWAYS COMPARE BETWEEN THE TWO HANDS

1st webbed space

1. Inspection

a. Skin
i. Discoloration
1. Erythema (cellulitis)
2. White (arterial insufficiency)
3. Blue/purple (venous congestion)
4. Black spots (melanoma)
ii. Trophic changes (i.e. increased hair growth or altered sweat production)
1. can represent derangement of sympathetic nervous system
iii. Wounds
1. Site & Size
2. Content (tendon or fat)
3. Edge
4. Attachment
iv. Scars
1. Site & Size
2. Color
3. Raised or not
4. Edge
b. Prominent swelling
c. Muscle atrophy
i. Thenar atrophy
1. Median nerve involvement
a. caused by carpal tunnel syndrome
ii. Interossei atrophy
2. Ulnar nerve involvement
a. caused by cubital tunnel or cervical radiculopathy
iii. Subcutaneous atrophy
3. locally post-steroid injection
iv. Hypothenar atrophy
4. Ulnar nerve lesion
 d. Deformity
i. Asymmetry
ii. Angulation
iii. Rotation
iv. Absence of normal anatomy (previous amputation)
v. Cascade sign
1. fingers converge toward the scaphoid tubercle
when flexed at the MCPJ and PIPJ
2. if one or more fingers do not converge, then
trauma to the digits has likely altered normal
alignment

In resting hand:

▪ Extension of the wrist, flexion of the fingers.

▪ Flexion of the wrist, extension of the fingers.

Extremely helpful in coma patient to assess their tendon integrity:

In a relaxed hand squeeze the forearm, fingers will be flexed

look for the alignment of the fingers they should point toward
the scaphoid.

2. Palpation
Ask the patient to place their hands back on the pillow, in a supine position:
▪ Assess temperature
o 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
 Warm: infection, inflammation
 Cool: vascular pathology
▪ Assess the muscle bulk of the thenar eminence and hypothenar eminence
o Compare for asymmetry, caused commonly by disuse or denervation (i.e. carpal tunnel
syndrome)

▪ Assess the tendons of the hand by feeling for nodules or contractures

Ask the patient to pronate their hands:

▪ Palpate the bony anatomy of the hands, feeling for any tenderness
o The radial and ulnar styloid processes
o The carpal bones
o Along the length of each metacarpal
 ▪ Gently squeeze all 4 MCP joints together
▪ Bimanually palpate all of the MCP joints, PIP joints, and DIP joints
 Tenderness
 Crepitus (fracture)
 Clicking or snapping (tendonitis)
 Joint effusion (infection, inflammation, trauma)

3. Movement
To assess the range of movement of each joint
▪ Active (by the patient)
▪ Passive

((Adapted from Hebani))

Place pt.
hands on
the table
and then
preform
To assess the integrity of Flexor Digitorum these To assess the integrity of Flexor Digitorum
Profundus (FDP) tests Superficialis (FDS)
MCP + PIP joints held in extension while patient MCP, PIP and DIP of all fingers held in extension
asked to flex FDP, thereby isolating FDP (from FDS) with hand flat and palm up; the finger to be tested
as the only tendon capable of flexing the finger. is then allowed to flex at PIP joint.
4. Neurological examination

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

Two-point discrimination (2 PD) test

▪ Used incase suspecting a nerve compression\lesion.

▪ Static 2 PD : vertical contact with the skin for one second with a
minimal amount of pressure such that that the skin just began to blanch.
The subjects were asked to say either “one point” or “two points.”

▪ Dynamic 2 PD: the procedure is same as static but the discriminator is

stroked along the volar surface of little figure. Randomly “one point” or
“two points’’ were applied to avoid false result.
▪ 3mm for dynamic.
▪ 6mm for static.
 Hand cases

▪ 1st you’ve to do ATLS.

▪ Left hand.
▪ The radial side of the thumb is only visible & it’s normal.
▪ The palm of the hand looks normal.
▪ There are 4 amputated fingers, each at a different level
but mainly at or distal to the PIPJ.
▪ In index & middle fingers I can see a whitish parts that
could be a bone or tendon.
▪ The fifth digit has a sharp cut of the tip of the finger.
▪ The amputated part looks pale.

▪ Deviation of the 4th digit of the right hand to the ulnar side.
▪ Overlapping of the 4th digit of the right hand to the ulnar side.

^ different ways to describe this deformity

▪ Rotational fracture.
▪ It also can be called finger scissoring.
▪ Mainly caused by fracture of the metacarpal bone.
▪ Indication for surgery.

▪ Right hand.
▪ Patient is asked to relax their hand.
▪ FDP is intact because there’s a slight flexion of the DIP
of the index finger.
▪ There’s a previous skin scar at the palm of the hand.
▪ There’s a skin wound at the distal ventral forearm.