EXAMINATION OF HAND

&
COMMON HAND INJURIES
Under following heads
• Why is it important?
• Basic anatomy
• Clinical examination
• Common injuries
Hand Injuries
The Importance of the Hand
• Communication

• Sensation

• Employment

• Independent Living
The Hand - Communication
• Greetings
Communication…
• Gestures
Communication…
• Sign Language
Sensation
• Large area brain structure devoted to touch. Highly sensitive.
Sensation…
• Relationships
Employment
• Use of hands fundamental to most vocations.
Independent Living
• Without the use of our hands, most people would find independent
living impossible.
 ANATOMY
&
CLINICAL EXAMINATION
General Plan of Upper Limb
• The upper Limb of Humans is built for PREHENSION &
MANIPULATION
• The range of movements available at the joints of the upper limb enhances
the dexterity of the fingers

. Four fingers flexing against an opposed thumb enable the hand to

function as a grasping mechanism ,in which the thumb is equal in
functional value to all fingers

The hand is furthermore the main tactile organ, with rich nerve supply
 Hand
 Hand is composed of a bony framework :
 8 carpals bones
 5 metacarpals
 14 phalanges
Anatomy of wrist
 Carpal Bones
 The names reflect on their shape

Divide in two rows; proximal and distal row
Proximal row:
From lateral to medial
Scaphoid, lunate, triquetrum and pisiform

Distal row
From lateral to medial
trapezium, trapezoid, capitate and hamate
 8 bones of Carpals
 A – Scaphoid (boatlike)
 B – Lunate (moon-shaped)
 C – Triquatrum (three-cornered)
 D – Pisiform (pea-shaped)
 E – Trapezium (four sided figure)
 F – Trapezoid
 G – Capitate (head-shaped)
 H – Hamate (hooked)

Try this pneumonic!!: She Look Too Pretty, Try To Catch Her
For all practical purposes only
3 Bones are important
1 Capitate
2 Lunate
3 Scaphoid
And out of these 3 also , majority of the time we are dealing with
SCAPHOID
Scaphoid
 70 % fractures involve the scaphoid
 Fall on outstretched hand – force is
transmitted from the capitate through
the scaphoid to the radius

 FOOSH…Fall on out stretched hand

 Flexor Retinaculum
 The flexor retinaculum (transverse carpal
ligament , or anterior annular ligament ) is a strong,
fibrous band, which arches over the carpus.
 Converting the deep groove on the front of the
carpal bones into a tunnel, the carpal
tunnel
 Flexor tendons of the digits and the median
nerve pass.
 Extensor Retinaculum

 The extensor retinaculum (dorsal carpal ligament

) is an anatomical term for the fascia that holds
the tendons of the extensor muscles in place.
 It is located on the back of the forearm, just
proximal to the hand.
Wrist Movement
 Thumb Movement

Thumb opposition Thumb adduction Thumb abduction

Adduction / abduction digits at MCP
Thumb extension / flexion at
MCP / CMC
Flexion Digit at PIP / DIP
 Extrinsic
Hand Muscle
 Extensor Pollicis Longus
Origin – posterior surface of middle of ulna and
interosseous membrane
Insertion – base of distal phalanx of thumb
Action
 extend distal phalanx of the thumb at interphalangeal
joint
 Assist in extension of thumb at metacarpophalangeal
and carpometacarpal joint.
 Assist radial deviation and extension hand at wrist
joint.
Nerve innervations - Radial nerve
 Abductor Pollicis Longus
Origin – posterior surface of middle
of radius and ulna and
interosseous membrane
Insertion – base of first
metacarpals
Action
 Abducts and extends thumb at
carpometacarpal joint
 Abducts hands at wrist joint
Nerve innervations – Radial nerve
 Extensor pollicis brevis
 Origin – posterior surface of middle of radius and
interosseous membrane.
Insertion – base of proximal phalanx of thumb
Action
 Extends proximal phalanx of thumb at

metacarpophalangeal joint
 Extends1st metacarpal of thumb at carpometacarpal

joint
 Assists in radial deviation at wrist joint

Nerve innervations – Radial nerve

 Surface anatomy of hand

The tendons that are palpated with thumb

abducted and extended form an anatomic
snuff- box
 Surface anatomy of hand

 Flexor Tendons:
1Flexor carpi radialis
2 flexor carpi ulnaris,
3palmaris longus
Clinical Examination of wrist and hand
General Principles
• Examine the patient while “ Sitting “
• Compare both hands
• Expose both upper limbs till shoulder
• Place both hands on a pillow or trolley
• Inspection
…. Dorsal aspect
…. Palmer aspect
• Palpation
• Range of motion
• Functional assessment
• Special tests
INSPECTION
Dorsal aspect
1 skin
Texture
Colour
Inflammation
Creases
Trophic changes
Dorsal aspect
2Nails
Colour
Shape
Clubbing
Koilonychia
brittle
Dorsal aspect

3Swelling
Distribution
Wrist
MCPJ
PIP
DIP
symmetry
Deformities
Wrist
radial or ulnar deviation
prominent ulnar styloid
Deformities
Metacarpophalangeal joints
ulnar deviation
subluxated or dislocated joint
FINGERS
Swan neck
Boutonierre
Mallet
Herberden nodes
Bouchard ‘s nodes
SWAN NECK DEFORMITY
Boutonierre Deformity
 Boutonierre
MALLET

SWAN NECK
Mallet finger
Bouchard nodes
MUSCLE WASTING
• Guttering of the dorsal aspect of the hand

• Guttering of the
fist web space
INSPECTION
Palmer aspect
1Skin
Colour
Vasculitis changes
Creases
Palmer erythema
Contracture ( duyptren’s contracture )
2 Swelling
wrist
MCP joints
I/P joints
Muscle Wasting
Thenar eminence
Hypothenar eminence
DEFORMITY
• Claw hand
CLAW HAND
• Simian Hand
• Wrist drop
PALPATION
Temperature
Dryness of skin
Tenderness
Joints
Wrist
MCP
PIP
DIP
TENDERNESS
Bones
Carpal
Metacarpal
phalanges
Tenderness
• Over the flexor tendon sheaths….
signifies inflammation of the tendon

1 Trigger finger
2 Tenosynovitis
3 Ganglion
Range of Motion
• Wrist
Functional ASSESSMENT
• Grasp
• Key punch
• Pincer grip
SPECIAL TESTS

1 Finkelstein test
2 Tinel sign
3 Phalen test
4 Froment test
5 OK sign
6 Wrist drop
7 Hitch Hike
8 Finger allignment
Finkelstein test
Tinel Test
Phalen Test
Froment test
WRIST DROP
 Frequently Presenting Hand Injuries

• Lacerations/Penetrating Injuries
• Amputations
• De-gloving Injuries
• Human (punch) Bites
• Animal Bites
• Hand infections
• Fractures
Lacerations
• Very common cause of trauma.
• Typical culprits –
Common Results
Lacerations
• Regardless of size, always have a high suspicion for more serious
injury.
• Remember, glass only ever stops cutting when it hits bone.
• Lacerated tendon when repaired takes 6-8 weeks of healing and hand
therapy to recover.
• Nerve repairs often take 3-6 months to get some benefit from the
repair
 Tendon injuries

Extensor tendon Injury:

• Divided into Zones according to anatomical location
of injury
• In the hand and wrist there are 7 extensor tendon
zones
Zone Presentation Management

•Closed: splinting 6-8 weeks

I Mallet Deformity •Open: suture repair for fixation.
Soft tissue reconstruction

•Closed: splinting MCP and PIP in

Boutonniere’s hyperextension for 6 weeks
III Deformity •Open: suture repair (figure of 8
suture)

•Closed: splinting ,45 extension at

V Fixed flexion of MCP wrist and 20 flexion at MCP
•Open: suture repair.

VII Fixed flexion of MCP •splinting

Suture repair followed by post-op
Deformities
can be due to tendon, bone , nerve injury and joint dislocations

• Specific types –
Tendon injuries

• Mallet finger
• Boutonniere deformity
• Swan neck
deformity
 Flexor tendon injuries –
5 zones in the hand and the wrist

Zone 1 One tendon only (FDP)

from middle of middle phalanx
FDS Insertion
distally
Zone 2 Two tendons (FDS &
FDP) from MCP joints to middle
Flexor Sheath of middle phalanx
Zone 3 Central palm
Zone 4 Tendons in the carpal
tunnel
Zone 5 Tendons proximal to the
carpal tunnel
Amputations
• Can occur at any level.
• Ability to re-plant / re-vascularise depends on both the level of
amputation and the mechanism.
• Once past the distal third of the distal phalanx the vessels are too
small to be anastamosed.
Finger Tip Amputation
Injured components may include skin, bone,
nail, nail bed, tendon, and the pulp, the
padded area of the fingertip .
• If just skin is removed and the defect is less than a centimeter
in diameter, it is often possible to treat these injuries with
simple dressing changes.
• If there is a little bit of bone exposed at the tip, it can
sometimes be trimmed back slightly and treated with V-Y
plasty
Amputation...
Reattachment
Decision is based on:
 Importance of the part,
 level of injury,
 mechanism of injury
 expected return of function.
• cold ischemia time 
• In surgery, the time between the chilling of a tissue, organ, or body
part after its blood supply has been reduced or cut off and the time it
is warmed by having its blood supply restored. This can occur while
the organ is still in the body or after it is removed from the body if the
organ is to be used for transplantation.
• warm ischemia time 
• In surgery, the time a tissue, organ, or body part remains at body
temperature after its blood supply has been reduced or cut off but
before it is cooled or reconnected to a blood supply.
Recommended ischemia times for replantation:
◦ Major replant: 6 hours of warm and 12 hours of cold
ischemia.
◦ Digit: 12 hours for warm ischemia and 24 hours for cold
ischemia.

Preoperative preparation: radiography of both

amputated and stump parts to determine the level of
injury and suitability for replantation
Preservation of amputated part
 we often see patients in the emergency room after
unfortunate accidents involving their fingers. Most people
bring the part in "on ice." Unfortunately, putting it directly on
ice can damage the tissue. The best way to preserve the part
is to wrap it in gauze moistened with saline (salt water),
place the wrapped part in a plastic sealable bag, and put the
bag on ice. This helps to preserve the tissue in case the
surgeon is able to reattach (or "replant") the part. This is a
great technique to remember; hopefully, you never will have
to use it! 
 Outcome

Overall success rates for replantation approach 80%.

Better outcome with Guillotine (sharp) amputation (77%) compared to
severely crushed and mangled body parts(49%). In general, the
prognosis for ring avulsion injuries is poor.
Studies have demonstrated that patients can expect to achieve 50%
function and 50% sensation of the replanted part.
De-gloving Injuries
Followup
• Can get large areas of skin loss.
• Typically treated as a skin graft with original skin, or debrided and skin
grafted from the thigh.
• Can get contraction of the scar.
Punch Bite Injuries
• Very common.
• Injury occurs after punching someone in the mouth. Usually small
laceration to the 2nd or 3rd MCPJ. Often extends into the joint with
damage to the extensor tendon.
• Always requires IVABs and a washout.
• Common consequences – septic arthritis, extensor tendon loss.
Punch Bite
Followup
• Usually require at least 1 washout. Sometime multiple.
• Tendon cannot be repaired if already infected.
• Tendon, although intially intact can be completely destroyed by
infection.
• Always, always refer.
Animal Bites
• Cat bites – frequently become infected. Cat teeth puncture like a
needle and deposit bacteria at the base to then form an abscess.
• Dog bites – easier to treat than cat bites as dog teeth typically tear
leaving the wound open and able to be irrigated. Cosmetically more
difficult to treat.
Paronychia
• infection of the finger that involves the tissue at the edges of the
fingernail

• superficial and localized to the soft tissue and skin

• most common bacterial infection seen in the hand ( staph; strep).

Paronychia treatment
• wound care alone.

• collection of pus - drain.

• a simple incision over the collection of pus to allow
drainage.
• scalpel may be inserted along the edge of the nail to
allow drainage.
• If the infection is large, a part of the nail may be
removed.

• oral antibiotic.
• wound care at home.
Felon
• infection of the fingertip.

• This infection is located in the fingertip pad and soft tissue associated
with it.
Felon treatment
• incision and drainage
• incision will be
made on one or
both sides of the
fingertip.
• break up the
compartments
• gauze will be
placed into the
wound to aid
the initial
drainage.
• flush out with a
sterile solution
• antibiotics.
Infectious flexor tenosynovitis &
Deep space infection
• infection involves the tendon sheaths and deep
spaces

• penetrating trauma that introduces bacteria

• surgical emergency and will require rapid treatment

with IV antibiotics.
Kanavel’s cardinal signs
• intense pain
• along the course of tendon with extension
• this is the earliest and most important sign
• flexion posture

• uniform swelling

• percussion tenderness along the course of the

tendon sheath
Fractures and dislocations
Diagnosis…..

• Tenderness in anatomical
Snuff box

• Xray- fracture line

Treatment
• Scaphoid cast (3-4 months)

• Dorsiflexion
& radial deviation
(glass holding
position)
• Internal fixation

• Herbert’s screw
Complications
• Avascular necrosis

• Delayed / non union

• Wrist osteoarthritis
Lunate dislocations
• Lunate dislocation
perilunate dislocation

• Open reduction

• Avascular necrosis
Bennett’s fracture dislocation
• Base of 1st
metacarapal

• Intra articular

• Longitudinal force
to thumb
Rolando Fracture
• Comminuted First Metacarpal Base #
• Presents as ‘Y’ or ‘T’ Pattern
• Differs from Bennette that usually no diaphyseal displacement
#dislocation of 5th mc , reduced and fixed with k wires
Fracture
•
phalanges
Fall of heavy object or crush injury

• Undisplaced
Displaced

• Strapping

• Open reduction
 PIPJ dislocations/
volar plate disruption
PIPJ dislocation
• Mechanism of Injury – hyperextension of the PIP
joint
• with or without dislocation
• often initial injury seems trivial
 PIPJ dislocation

• If dislocation without #
OR
If # fragment less than 30% joint
surface

→ reduce then manage

conservatively in dorsal blocking
splint (DBS)
CARPAL TUNNEL SYNDROME
• Carpal tunnel syndrome is perhaps the most common
nerve disorder
experienced today; and while it is usually very
treatable, that doesn’t lessen the fact that it
affects the lives of 4-10 million Americans
According to a study, it was found that “Carpal tunnel syndrome” is
themost common nerve compression disorder of the upper extremity.

This process affects 1% of the general population and 5 % of the

working population who must undergo repetitive use of their hands
and wrists in daily living.
Surgical treatment for carpal tunnel syndrome is the most frequent
surgery of the hand and wrist.
With 463,637 carpal tunnel releases annually in the United States &
accounting for $1 billion in direct costs.
There are 25000 ortho. Surgeons in USA
Means average more than
100 CTS surgeries annually for orthopods who are doing these.
• While carpal tunnel syndrome can be treated, after reading these
statistics, it should become ever clear the value of preventive
measures.

• However, in order to do that, the first step is education.

• The kind of activity that is associated with increased
risk for development of carpal tunnel syndrome is the
ones where there is
• constant pressure on the volar aspect of the hand eg.
Wheelchair users, cycling
• associated with constant flexion and extension of the wrist
joint eg tennis
• use of vibrating equipment
• (highly repetitive or forceful exertions of the hand and the wrist)
• Other conditions associated with carpal tunnel syndrome are: arthritic
conditions, pregnancy and rheumatoid conditions .
SYMPTOMS
SYMPTOMS
1 Numbness

Possibly the most common of symptoms associated with carpal

tunnel syndrome, a sensation of tingling or numbness is often
experience as a result of the undue pressure on the nerves in
the hand. 

In this condition , this feeling usually occurs on the palm side

of the index, middle and ring finger
2. Pain That Worsens At Night

It is important to note that pain, at least in terms of carpal tunnel

syndrome, should be considered a recognizably
different sensation than tingling or numbness. 

For people with carpal tunnel syndrome, the act of falling asleep may
come easily enough,

but it may be followed by being awakened by severe pain in the hand,

wrist .
3. Stiff Hands in The Morning

Many carpal tunnel syndrome patients report

mornings being the most difficult time of day

for them with one or both hands feeling

stiffer than usual.

4. Loss of Muscle Strength

Among the most commonly reported symptoms of carpal tunnel

syndrome are a gradual loss of muscle strength in the hand, wrist and
fingers.
5. Burning Sensation
While tingling and numbness is the most common sensations

experienced with carpal tunnel syndrome; some patients report an

accompanying burning sensation in their hands.

6 Hand Weakness

While this symptom might seem like the embodiment of carpal

tunnel syndrome,
7 Inability to do intricate works

Many patients with this condition report losing the

ability to perform intricate hand movements, mainly
because it involves the use of small muscles at the
base of the thumb.
8 Feeling of swelling of fingers

The fingers themselves might not appear swollen, a

common symptom of carpal tunnel syndrome is the
feeling of one's fingers being swollen, evidently,
without them actually being swollen. 
9 Inability to Feel Hot or Cold

While most of the signs and symptoms associated with

carpal tunnel syndrome are relatively straightforward and
make sense, this last sign is definitely the most interesting. 
Diagnosis

• The diagnosis can be made based on the history and clinical

examination.
• With examination:
• positive Tinel and Phalen test
• reproduction of the symptoms2
(compression of the arm with a Blood pressure cuff or holding the wrist in full
palmar flexion for a minute).
• Electrical studies are used to confirm the diagnosis,
not for diagnosis purposes2,7
• more important in those with significant motor loss or
those with atypical signs or symptoms7.
• Can also be used to determine the severity of the
motor loss in order to determine the prognosis.

• Ultrasound can also be used to diagnose carpal tunnel

syndrome9.
Investigations

Tinel test
Nerve conduction studies
 Differential diagnosis

• Rheumatic conditions
• Cervical disc disease (Cervical spondylosis, C6 and C7)
• Proximal entrapment of the median nerve
• Thoracic outlet syndrome
Management

• Conservative or surgical
• The aim of treatment is aimed at both resolving the
symptoms and fastest restitution of the hand and
compressed nerve functions
• nerve stability, conductivity, condition and strength8.
• The choice of management depends on the duration
and the severity of the condition8.
Conservative
• Preferably for the not so severe conditions and those
who do not want surgical treatment.
• Symptoms usually disappear after nine month in 50%
of the patients4 with 22% continuing to have
symptoms after 8years4.
• Night splints (prevents wrist flexion)
• NSAIDS
• Single dose steroid injection3,8
• reduce the inflammatory process
• reduction in the swelling
• nerve compression.
• Improvement of symptoms.
• More effective in the earlier course of the disease.
• Can be reserved for those in which conservative
therapy shows no improvement in symptoms after 6
months2,4 .
• Changing the activity type4.
 
• Ischaemic compression therapy (newer modality).
Elimination of the trigger points along the course of
the median nerve. Symptoms improve without
change in the median nerve itself 4.

• Gabapentin6, effects thereof in the treatment of

symptoms of carpal tunnel syndrome were looked at
based on its efficacy in the treatment of neurologic
pain.
Surgical

• Endoscopic versus open surgery

• If symptoms remain pronounced
• decline in motor and sensory functions4.
• Carpal tunnel release necessary for complete relief of symptoms,
either partial or complete division of flexor retinaculum.
• Loss of relief of symptoms from surgery occurs in about a third of
patients after about 2years4.
• Pain in the scar tissue and weakening hand have also been reported4.
Rehabilitation

• Occupational therapy and physiotherapy

referral
• post-operative for hand rehabilitation.
• Yield in a faster return to activity
Prevention

• Padded gloves, protect the

ulnar surface of the wrist
• Adjusting technique
• Occupational, adjusting the
weight and duration of
activity
• Maintaining wheelchairs in
good condition10
Take home message
• The interventional options will depend on the level of
activity participation and the type of activity.
• Rehabilitation post therapy is important in the
maintanace of hand function, retaining of sport
specific hand function and early return to play
 Trigger finger



Trigger finger is a painful condition that causes the
fingers or thumb to catch or lock when bent. In the thumb its
called trigger thumb.

 Trigger finger happens when tendons in the finger or

thumb become inflamed. Tendons are tough bands of tissue
that connect muscles and bones. Together, the tendons and
muscles in the hands and arms bend and straighten the fingers
and thumbs.
 A tendon usually glides easily through the tissue that
covers it (called a sheath) because of a lubricating membrane
surrounding the joint called the synovium. Sometimes a tendon
may become inflamed and swollen. When this happens,
bending the finger or thumb can pull the inflamed tendon
through a narrowed tendon sheath, making it snap or pop.

 Symptoms


 Symptoms of trigger finger usually start without any
injury, although they may follow a period of heavy
hand use. Symptoms may include:
 A tender lump in palm
 Swelling
 Catching or popping sensation in finger or thumb
joints
 Pain when bending or straightening your finger
 Stiffness and catching tend to be worse after inactivity,
such as when wake in the morning. fingers will
 What Causes Trigger Finger?


A repeated movement or forceful use of the finger or
thumb.
 Rheumatoid arthritis
 Gout
 Diabetes
 Grasping something, such as a power tool,
firm grip for a long time.
 Who Gets Trigger Finger?

 Trigger finger is more common in women than
men

It tends to happen most often in people who are 40

to 60 years old.
 Farmers
 Industrial workers
 Musicians often get trigger finger since they ep
reat
finger and thumb movements a lot
 Smokers can get trigger thumb from repeated
use of a lighter.
 How is trigger finger treated?

In some people, trigger finger may get better without
treatment. However, If treatment is necessary, several different
options are available, including:
 Rest and medication – avoiding certain activities and taking non-
steroidal anti-inflammatory drugs (NSAIDs) may help relieve
pain.
 Splinting – this involves strapping the affected finger to a plastic
splint
to help ease your symptoms.
 Corticosteroid injections – steroids are medicines that may be used
to reduce swelling.
Surgery on the
affected sheath

surgery involves releasing the

affected sheath to allow the
tendon to move freely again.
This is a relatively minor
procedure generally used when
other treatments have failed. It
can be up to 100% effective,
although may need to take two
to four weeks off work to
fully recover.
 Complications


Incomplete extension — due to persistent
tightness of sheath beyond the part that was release

Persistent triggering — due to incomplete release of

the first part of the sheath

Bowstringing — due to excessive release of the

Sheath
 Recovery

 Most people are able to move their fingers
immediately after surgery.
 It is common to have some soreness in palm.
Frequently raising hand above heart can help reduce
swelling and pain.
 Recovery is usually complete within a few weeks, but
it may take up to 6 months for all swelling and stiffness
to go away.
 If finger was quite stiff before surgery, physical
therapy and finger exercises may help loosen it up.