Modern Study Review (AI-Generated)
High-Yield Summary
The hand exam is a cornerstone of musculoskeletal and neurological assessment, essential for diagnosing a wide spectrum of conditions from traumatic injuries to chronic inflammatory diseases. A systematic approach combining observation, range of motion (ROM), functional grip assessment, and specific tendon and ligament tests optimizes diagnostic accuracy. Modern practice emphasizes correlating clinical findings with advanced imaging and electrodiagnostic studies to guide treatment focused on restoring pain-free function and dexterity.
Key Diagnostic Findings
| Aspect | Key Points |
|---|
| Anatomy & Observation | Bone and soft tissue contours, deformities, scars, muscle wasting (thenar/hypothenar), swelling, vasomotor and trophic changes. |
| Range of Motion (ROM) | Forearm pronation/supination (85-90°), wrist flexion/extension (70-90°), radial/ulnar deviation, finger and thumb joint flexion/extension with normative values. |
| Functional Grip | Power grips (hook, fist, cylinder, spherical), precision grips (three-finger pinch, key pinch, tip pinch). |
| Muscle/Tendon Testing | Isolated testing of flexor digitorum superficialis/profundus, extensor digitorum communis, extensor indicis, interossei, thumb muscles (FPL, EPL, EPB, APL, APB, adductor pollicis). |
| Special Tests | Finkelstein’s test (De Quervain’s tenosynovitis), Bunnell’s test (intrinsic tightness vs. capsular contracture), Watson test (scapholunate instability), Lunatotriquetral ballotment (lunotriquetral dissociation), Piano key test (distal radioulnar joint stability). |
Current Gold Standard Treatment
| Condition/Indication | Non-Operative Treatment | Operative Indications |
|---|
| Tendinopathies (e.g., De Quervain’s) | NSAIDs, splinting, corticosteroid injections, activity modification | Surgical release if persistent symptoms >3-6 months or tendon rupture |
| Carpal Instability (e.g., scapholunate) | Immobilization, hand therapy, NSAIDs | Ligament repair/reconstruction for symptomatic instability or chronic pain |
| Contractures (intrinsic tightness) | Stretching, splinting, occupational therapy | Surgical release or capsulotomy if functionally limiting |
| Distal Radioulnar Joint (DRUJ) instability | Immobilization, bracing | Surgical stabilization for chronic instability or pain |
Modern Complications & Outcomes
- Complications: Persistent stiffness, chronic pain, tendon adhesions, nerve injury, complex regional pain syndrome (CRPS), and recurrent instability.
- Outcomes: Early diagnosis and targeted therapy improve pain relief and functional restoration. Surgical outcomes depend on timing, technique, and rehabilitation adherence.
- Board Exam Focus: Know the normative ROM values, key special tests (Watson, Finkelstein, Bunnell), and indications for surgical referral. Emphasize functional assessment and correlation with imaging.
Classic Clinical Notes
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
| Movement | Normal Range (Degrees) |
|---|
| Pronation of forearm | 85-90° |
| Supination of forearm | 85-90° |
| Wrist abduction (radial dev.) | 15° |
| Wrist adduction (ulnar dev.) | 40° |
| Wrist flexion | 80° |
| Wrist extension | 70-90° |
| Finger flexion (MCP) | 85-90° |
| Finger extension (MCP) | 30° |
| Finger flexion (PIP) | 100-115° |
| Finger extension (PIP) | 0° |
| Finger flexion (DIP) | 80-90° |
| Finger extension (DIP) | 20° |
| Thumb flexion (CMC) | 45-50° |
| Thumb extension (MCP) | 0° |
| Thumb flexion (MCP) | 50-55° |
| Thumb extension (IP) | 0-5° |
| Thumb flexion (IP) | 85-90° |
| Thumb abduction | 60-70° |
| 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 others held extended
- Flexor digitorum profundus – flexion of the DIP
- Extensor digitorum communis – active extension of MCP with wrist extended
- Extensor indicis – extension of index MCP with others flexed
- Extensor digiti minimi – extension of little finger MCP with others flexed
- Interossei – finger adduction/abduction with MCP extended
- Abductor digiti minimi – abduction of little finger against resistance
- Opponens digiti minimi – flexion of 5th metacarpal against resistance
- Flexor pollicis longus – flexion of distal thumb phalanx against resistance
- Extensor pollicis longus – retroposition of thumb, hyperextension of IP joint
- Extensor pollicis brevis – extension of proximal phalanx with IP flexed
- Abductor pollicis longus – retroposition of thumb, tendon palpable at snuffbox edge
- Abductor pollicis brevis – abduction of thumb
- Adductor pollicis – approximation of 1st and 2nd metacarpals without thumb flexion, wrist extended
- Swelling, crepitus, pain over tendons indicate inflammation
Special Tests
- Finkelstein’s test – EPB/APL tenosynovitis
- Bunnell’s test – detects intrinsic contractures vs. joint capsule contracture
- MCP slightly extended, PIP passively flexed: if PIP does not flex, tight intrinsics or capsule contracture suspected
- MCP flexed: PIP flexes if intrinsics tight, does not flex if capsule contracted
Wrist Evaluation
Carpal Instabilities
- Grip strength
- Palpable/audible clunk on radial/ulnar deviation or flexion/extension
- Tenderness at scapholunate ligament (distal to Lister’s tubercle)
Watson Test
- Dorsally directed pressure on scaphoid tubercle during radial deviation causes proximal pole subluxation and pain
- Ulnar deviation reduces subluxation with a palpable “clunk”
Lunatotriquetral Ballotment
- Examiner grasps triquetrum and lunate, moves lunate anteroposteriorly
- Laxity, crepitus, or pain = positive test for lunatotriquetral dissociation
DRUJ Stability – “Piano key test”
- Hold distal ulna between index and… (text incomplete)
Last Updated on January 24, 2026 by orthonet
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