Hand

Screen Test

• Expose above elbows
• Make a fist and open hands with palms up
• Raise arms above up to look at elbows and posterior aspect arms

Refine Exam

Swelling

• Inspect and Describe:
  • Location
  • Shape
  • Size
  • Overlying skin changes
• Palpate:
  • Firmness
  • Mobility
  • Attachment to underlying structures
  • Pain
  • Pulsatility
  • Skin temperature

Special Tests

• Distal neurology & vasculature
• Allen’s Test (especially if volar radial ganglion):
  • Assess blood flow to the hand by occluding radial and ulnar arteries alternately.

Dupuytren’s Contracture

Look

• Scars
• Pits
• Cords
• Garrod’s Pads

Feel

• Throughout palm
• Correctibility of deformities
• Sensation and vascularity (if past surgery)

Special Tests

• Hueson’s Table Top Test
• Measure contractures with goniometer
• Ask if other parts of body are affected

Functional Assessment

• Assess hand function for daily activities

Rheumatoid Arthritis

Look

• Comment on elbow or shoulder problems on screening
• Extensor Surface Features:
  • Skin appearance
  • Scars
  • DRUJ arthritis, prominence (caput ulna)
  • Wrist radial deviation
  • Dropped finger at MCPJ
  • Ulnar deviated fingers
  • MCPJ subluxation
  • Z Thumb
  • Boutonnière, Swan neck, or mallet deformities
  • Rheumatoid nodules
  • Joint inflammation
• Flexor Surface Features:
  • Skin appearance
  • Scars (CTD or trigger finger scars)
  • Trigger finger
  • Finger deformities

Functional Testing

• Grip, hook, pinch:
  • Grasp my hand as tight as possible
  • End pinch (pen)
  • Chuck pinch (coin)
  • Side pinch (key)

Feel

• Pain in small joints
• Correctibility of deformities

Special Tests

• Neurological screening

Nerve Lesions

Radial Nerve

• Sensation:
  • 1st dorsal web space
• Motor:
  • ECRL
  • ED
  • EPL
  • Triceps (if ECRL weak)
• Differentiates between PIN and radial nerve palsy; ascertain if radial nerve palsy is very high or high by testing triceps.

Ulnar Nerve

• Sensation:
  • Little finger palm
  • Hypothenar skin
  • Dorsal hand
• Motor:
  • ECU
  • FDP little
  • ABDm
  • 1st dorsal interosseous
  • ADP (Froment’s Sign)
• Special Tests:
  • Tinel’s (cubital tunnel to Guyon’s canal)
  • Elbow flexion (provocation of ulnar nerve at cubital tunnel)
  • Wartenberg’s Sign (inability to adduct little finger)
  • 2-point discrimination and Semmes-Weinstein testing

Median Nerve

• Sensation:
  • Thenar eminence
  • Index palmar skin
• Motor:
  • FCR
  • FDS middle
  • OK sign
  • ABP
• Special Tests:
  • Tinel’s over forearm and hand
  • Phalen’s Test
  • 2-point discrimination and Semmes-Weinstein testing

Musculocutaneous Nerve

• Sensation:
  • Lateral forearm
• Motor:
  • Biceps

Axillary Nerve

• Sensation:
  • Regimental badge area
• Motor:
  • Deltoid
  • Teres minor

Wrist Pain

Look

• Same as for hand

Feel

• Systematic from radial volar around ulnar aspect then back to radial dorsal

Move

• Prayer and inverted prayer sign
• Passive range:
  • Pronation
  • Supination
  • Radial and ulnar deviation

Special Tests

• Finkelstein Test (De Quervain’s)
• Kirk Watson Test (SL instability)
• DRUJ Ballotment/Piano Key Test (DRUJ instability)
• Resisted Pronation Test (STT arthrosis)
• Thumb Grind Test (CMCJ arthrosis)
• Ulnar Grind Test (TFCC)
• Pisiform Compression Test (Pisotriquetral joint OA)

Intrinsic Plus or Minus Hand

Carpal Tunnel Syndrome

Look

• Neck scars and movements
• Screening of hands, wrists, and shoulders
• Scars on hand from past surgery
• Thenar wasting

Feel

• Sensation in radial 3 digits
• Sensation over thenar eminence (proximal lesion)
• Sensation over ulnar digits for comparison and screening
• Semmes-Weinstein and 2-point discrimination (earliest signs)

Move

• Neck movements (if not done already)
• APB power
• Intrinsic power for comparison and screening
• FDS to middle finger power (proximal screening)

Special Tests

• Tinel’s
• Durkin’s Compression Test (1-minute maximum)