Transcript Examination of the hand

Examination of the hand
C.Snyckers
The hand
• Without the human hand the most refined
creations of the human mind would be mere
theoretical concepts.
• The hand is the focal point of human beings’
interactions with the environment.
General hand functions
• 45% of work done by the hand – grasp
– Power function that require both intrinsic and extrinsic
coordination.
• 45% of work done by the hand – pinch
– Key pinch
– Tip pinch
– Chuck pinch
• 5% of work done by the hand – hook
• 5% of work done by hand - paperweight
Remember-The hand does not exist in
isolation!!!
• Shoulder and elbow position hand in space.
• Brain and c-spine relay neurological messages
to the hand.
• The hand is at one peripheral point of the
vascular system with end-arteries
• ‘Pre-flight’ check helpful prior to examining
the hand
Surface anatomy
• Remember – traditional terms (posterior,
medial etc.) replaced by:
– Volar
– Dorsal
– Ulnar
– radial
Surface anatomy
• Sensory supply
Surface anatomy- dorsum
• Dorsal aspect:
– Fingernails
• Alignment – point toward tubercle of scaphoid when
flexed
• smooth eponychium (cuticle)
• Pink nailbed
• Crescent lunula
• Many deformities of systemic or local origin
– Paronychium, subungual heamatoma
– Psoriatic pitting, splinter hemorrhages etc.
Surface anatomy- dorsum
• Digits
– Digits are straight with two areas of transverse wrinkles
marking the IPJ
• Check for
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Heberden’s nodes (OA) DIPJ
Bouchard’s nodes (OA) PIPJ
Mucous cysts
Erythema
Swelling (fusiform, eccentric)
Surface anatomy-dorsum
• Hand
– Dorsal skin loose
– Extensor tendons visible
– 1st dorsal interosseos most prominent muscle mass on
dorsum – atrophy with ulnar nerve injury
• Check for
– Tendonitis, swellings – rheumatoid arthritis
– ‘Dropped knuckle’ – trauma
– Bossing – metacarpal base II
Surface anatomy-dorsum
• Wrist
– Head of ulna – pro / supination and DRUJ
– TFCC- hollow just distal to head of ulna
– 6 extensor tunnels
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Extensor carpi ulnaris, extensor digiti minimi
Extensor digiti communis
Extensor pollicus longus – Lister’s tubercle
Extensor carpi radialis brevis, longus
Abductor pollicus longus, extensor pollicus brevis
– Snuffbox – scaphoid
– Mid wrist – scapho-lunate joint
• Check for
– Tenderness, ganglia, tendinitis, tendon ruptures
Surface anatomy-volar
• Hand - normal resting arcade of fingers
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Flexion finger creases – joints
Palmar skin tightly adhered for grip (palmar aponeurosis)
Distal & proximal palmar creases
Thenar/ hypothenar eminences
• Check –
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Fingertip abscess - felon
Loss of creases and tightness – infection
Contracture of the palmar aponeurosis – Dupuytren’s
Cardinal signs of Kanavel – septic tenosynovitis
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Fusiform finger swelling
Finger held in flexed position
Painful passive extension
Tenderness over the palmar surface along the tendon
Surface anatomy-volar
• Wrist
– Distal wrist flexion crease – proximal border of the flexor
retinaculum ( Carpal tunnel)
– Radial artery between flexor carpi radialis and abductor pollicus
longus
– Oppose thumb and little finger – palmaris longus (80% of people)
– Between palmaris longus and flexor carpi radialis – median nerve
– Ulnar side – pisiform bone – flexor carpi ulnaris
– Ulnar artery – radial to the flexor carpi ulnaris
• Check
– Synovitis – rhumatoid arthritis
– Ganglion - common
Finger deformities
• Mallet finger
– DIPJ remains in flexion –
• ext tendon rupture
• Rheumatoid arthritis
• Boutonniere
– Flexion PIPJ with extension DIPJ –
• central slip tear
• Rheumatoid arthritis
• Swan neck deformity
– Flexion DIPJ with extension PIPJ –
• Old mallet finger
• Rheumatoid arthritis
Hand deformities
• Ulnar claw hand – ulnar nerve lesion
– MCP hyperextention flexed PIPJ of little and ring
• Benedictine hand – median nerve lesion
– Poor middle and no index MPJ and PIPJ active flexion
• Claw hand – median and ulnar lesion
– Hooked claw of all fingers with MPJ extension
Range of motion - compare
• Wrist
– Dorsiflexion: 60°-70° Plantarflexion: 60°-80°
– Radial deviation: 20° Ulnar deviation :30°- 40°
• Also check – tenodesis effect
– wrist flexion should passively extends fingers –
extensor tendon injury
– Wrist extension should passively flex fingers –
flexor tendon injury
Muscle testing
• Abductor pollicus brevis – median nerve
function
• 1st dorsal interosseos – ulnar nerve function
• Finger ab/adduction - unlar nerve function
• Thumb PIPJ flexion for anterior interosseos
function
• MPJ extension – radial nerve function
Special tests
• Froment’s test and sign – ulnar nerve lesion
• Phalen’s test and Tinel’s test and sign
– carpal tunnel
Finkelstein
Quervain’s
Allen’s
test – de
test – vascular
supply of the hand