Hand Exam

Hand Exam

Observation

– bone and soft tissue contours – deformities, alignment
– skin creases
– scars
– muscle wasting – thenar and hypothenar eminences
– swelling or hypertrophy- ganglions, effusions, synovial thickenings
– vasomotor change – skin color and temperature
– sudomotor – sweaty skin
– trophic changes – smooth, nonelastic skin, hair changes

Range of Motion

– Active Range

Pronation of forearm (85-90o) Supination of the forearm 85-90o)

Wrist abduction / Radial deviation (15o) Wrist adduction / Ulnar deviation (40o)

Wrist flexion (80o) Wrist extension (70-90o)

Finger flexion MCP 85-90o Finger extension MCP 30o
PIP 100-115o PIP 0o
DIP 80-90o DIP 20o

Thumb flexion CMC 45-50o Thumb extension MCP 0o
MCP 50-55o IP 0-5o
IP 85-90 o

Thumb abduction (60-70o)

Thumb apposition – to all digits

Functional Assessment of Grip

– Power grip – hook, fist, cylinder, spherical grasp
– Precision grip – three fingered pinch, key pinch, tip pinch

Musculo/Tendinous Assessment

– Flexor digitorum superficialis – active flexion of the PIP of one finger while the others are held in full extension

– Flexor digitorum profundus – flexion of the DIP

– Extensor digitorum communis – active extension of the MCP with the wrist held in extension

– Extensor indicis – active extension of the MCP of the index finger with the MCPs of the long and ring finger held down in flexion

– Extensor digiti minimi – active extension of the MCP of the little finger with the MCPs of the long and ring finger held down in flexion

– Interossei – adduction and abduction of the fingers tested with the MCP’s extended

– Abductor digiti minimi – abduction of the little finger against resistance

– Opponens digiti minimi – flexion of the 5th metacarpal against resistance

– Flexor pollicis longus – flexion of the distal phalanx of the thumb against resistance

– Extensor pollicis longus – retroposition of the thumb, and hyperextension of the IP joint

– Extensor pollicis brevis – extension of the proximal phalanx with the IP joint flexed

– Abductor pollicis longus – retroposition of the thumb – palpate the tendon on the edge of the snuffbox

– Abductor pollicis brevis – abduction of the thumb

– Adductor pollicis – approximation of the first and second metacarpals without flexing the thumb (to eliminate the effect of FPL) and with the wrist extended (to relax EPL)

– swelling, crepitus, pain over the tendons – signs of inflammation

Finkelstein’s test – EPB/APL tenosynovitis

Bunnell’s test – aims at detecting contractures of the intrinsics
– the MCP is slightly extended, and the PIP is flexed passively. If the intrinsics are tight or a contracture of the joint capsule exists, the PIP will not flex. If the MCP is then flexed, the PIP will flex if the intrinsics were tight, but will not flex if the capsule is contracted.

Wrist Evaluation

Carpal Instabilities

– grip strength
– palpable or audible clunk on radial/ulnar deviation and/or flexion/extension
– tenderness at the scapholunate ligament (distal to Lister’s tubercle)

Watson Test
– numerous descriptions
– dorsally directed pressure on the scaphoid tubercle as the wrist is radially deviated subluxes the proximal pole over the dorsal lip of the radius as the scaphoid flexes. (This subluxation often causes pain, which some people describe as being a positive test). When the wrist is ulnarly deviated, the proximal pole eventually subluxes back and “clunks” into place. (This clunk is what some people describe as being a positive test.)

Lunatotriquetral Ballotment
– for lunatotriquetral dissociation
– the examiner grasps the triquetrum between the thumb and second finger of one hand, and the lunate with the thumb and second finger of the other. By moving the lunate anteroposteriorly, laxity, crepitus, or pain represents a positive test.

DRUJ stability – “Piano key test”
– hold distal ulna between index and