Examination of Hands

History: Hand dominance and occupation? Injury? Pain? Paresthesia? Impaired function? Swelling?

Position: Place the patient’s hands on pillow

Look: SEATS

a. Shape or Deformity:

– Wrist:

• Radial deviation: RA
• Ulnar deviation and flexion deformity: Spastic hemiplegia (CP)
• Wrist drop (also finger drop): Radial nerve injury
• Prominent dorsal ulnar and radial concavity (Manus valgus): Madelung’s deformity
• Dinner fork deformity: Colle’s fracture

– MCP joint:

• Ulnar deviation: RA, Jaccoud’s arthropathy (Post-rheumatic fever, SLE
• Flexed (extended PIP and DIP): Main d’accoucheur (Tetany)
• Hyperextension (flexed PIP and DIP) of 4th and 5th fingers (2nd and 3rd extended): Ulnar claw hand (Bishop’s hand/main-en-griffe)
• Short 4th and 5th metacarpals (Archibald’s or Knuckle knuckle dimple dimple sign): Pseudohyperparathyroidism, Turner’s syndrome
• Ulnar claw hand: Lumbricals (MCP flexion) and Interossei (Middle and Distal phalanges extension) paralysis

– PIP joint:

• Hyperextension (flexed DIP): Swan neck deformity (RA)
• Flexed (hyperextended DIP): Boutonniere or Button hole deformity (RA)
• Hyperextended interphalangeal joint (flexed MCP) of thumb: Z-deformity
• Flexed (palpable flexor sheath nodule, extends passively with snap): Trigger finger (RA)
• Flexion contracture of 4th and 5th fingers (Also MCP joint): Dupyutren’s contracture (Palmar fascia thickening due to Cirrhosis, DM, Phenytoin, Trauma)

– DIP joint:

• Flexion: Mallet/Baseball finger (Extensor tendon injury)
• Hyperextended: Boutonniere deformity
• Flexed: Swan neck deformity

– Fingers:

• Sausage shaped: Psoriatic arthropathy, Ankylosing spondylitis
• Main en lorgnette/Opera glass hand (Shortening and telescoping): Arthritis mutilans (Psoriasis, Advanced RA)
• Arachnodactyly (long, slender, spider like): Marfan’s syndrome
• Polydactyly or Amputation
• Syndactyly
• Clinodactyly (incurved fingers): Little finger’s in Down’s syndrome
• Bradydactyly (short fingers): Down’s, Turner’s syndrome, Mucopolysaccharidoses
• Sclerodactyly (tight skin over phalanges): Scleroderma
• Spatulate fingers with square tips: Acromegaly
• Dropped fingers

b. Swelling:

• Diffuse?
• Localized?

c. Erythema (Palmar erythema)

– Bright red and warm thenar eminence, hypothenar eminence, pulp and base of fingers
– Cause: Cirrhosis, Pregnancy, Hyperdynamic circulation
– Mechanism: Hyper-estrogenemia or Hyperdynamic circulation
– Demonstration: Blanches on pressure with glass slide

d. Atrophy

Small muscles of hand = Thenar, Hypothenar, Adductor pollicis
Thenar = OAF pollicis (median nerve)
Hypothenar = OAF digiti minimi (ulnar nerve)

Median nerve (Recurrent branch): Lateral 3 and 1/2 fingers (LOAF)

• Lumbricals – 1st and 2nd, Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis

Radial nerve (PIN branch): Extensor aspect of hand (BEAST)

• Brachioradialis (X), Extensors (carpi ulnaris, digitorum communis, indicis propius, pollicis brevis), Abductor pollicis longus, Supinator, Triceps (X)

Ulnar nerve: Medial 1 and 1/2 fingers (LOAF – I) and hypothenar

• Lumbricals – 3rd and 4th, Opponens digiti minimi, Abductor digiti minimi, Adductor digiti minimi, Flexor digiti minimi, Adductor pollicis

– Causes: LMN lesions (C8-T1)

• Leprosy (Peripheral neuropathy)
• Motor neuron disease (Anterior horn cells)
• Rheumatoid arthritis (Reflex disuse wasting)
• Poliomyelitis (Anterior horn cells)
• Syrigomyelia ((Anterior horn cells)

– Appearance:

• Thenar and hypothenar muscles: Flattening
• Interossei and lumbricals: Interosseous space in dorsum becomes hollowed or depressed
• Prominent tendons, knuckles and bony prominences

e. Tremors:

Involuntary, rhythmic, oscillatory movement about a joint or a group of joints resulting from alternating contraction and relaxation of muscles.

Classification:

1. Fine tremor (low amplitude, barely visible)

• Postural tremor:
  • Physiological: Anxiety, Senile tremor
  • Pathological:
    • Essential tremor (coarse or fine but slow): Autosomal dominant; may be improved by alcohol; head and neck involved by nodding tremor
    • Endocrine (Hyperthyroidism)
    • Drug-induced: B2-sympatho-mimetics (Salbutamol)
    • Alcohol or drug withdrawal
    • Demonstration: Patient attempts to maintain posture against gravity. A thin piece of paper is placed over the hands outstretched with separated fingers.

2. Coarse tremor (high amplitude)

• Resting/Static tremor:
• Pill rolling tremor (Parkinsonism): Patient attempts to maintain body position at rest. Flexed elbow, wrist and MCP joint with flexion-extension and rotatory movement between thumb and finger (thumb moving across tips of all fingers). It is improved by activity and worsened at rest. Proximal muscles, lips and tongues are also frequently involved.
• Intention tremor (Cerebellar lesion): Tremor amplifies as the target is reached. It is assessed with finger-to-nose test. Associated tremor of head is called titubation.
• Action or Kinetic tremors (MS, CVA, midbrain-red nucleus lesions): Occurs with any voluntary movement and abolished by rest.
• Flapping metabolic tremor/Asterexis/Bat’s wing tremor (Hepatic encephalopathy, Uremia, Respiratory failure – CO2 narcosis, Wilson’s disease): Asked to outstretch the arm with extended wrist and MCP joints and maintain this position for 20 seconds and look for flexion-extension of MCP joint OR Milkmaid’s grip
• Other tremors:
  • Isolated head tremor: usually dystonic and associated with torticollis
  • Hysterical tremor: limb or whole body and worsened by attempt to restrain

f. Skin and nails:

– Color:

• Pallor (Palmar creases): Anemia
• Icterus
• Cyanosis: Tips of fingers, nail beds and palms
• Janeway’s lesion: Non-tender, maculopapular lesion in thenar eminence (SABE)
• Nicotine staining (In right index and middle fingers)

– Scars, Hair distribution, Glistening, Tightening (Scleroderma), Ulcers, Pulsations, Hyper/hypopigmentation, Palmar xanthoma

– Nail:

• Nail folds: Clubbing, Dilated capillary loops (Scleroderma), Paronychia (Inflamed swollen nail folds – wet workers, DM)
• Nail bed:
  • Splinter hemorrhage (Linear longitudinal hemorrhage/infarcts): SABE, trauma, vasculitis
• Nail plate:
  • Longitudinal ridging and beading: Ageing
  • Shiny or polished nails: Pruritus
  • Bitten nails: Anxious personality
  • Pitting: Psoriasis, eczema, alopecia areata
  • Onycholysis (loosening of nail from bed): Psoiasis, Ringworm, trauma, Lichen planus
  • Koilonychia (brittle, flat, spoon-shaped): Chronic IDA
  • Transverse ridging (Beau’s line): Recent acute illness, Zn deficiency
  • Leukonychia (White or Terry’s nails): Hypoalbuminemia (CLD, Malnutrition)
  • Red lunula (Red half moons): CHF
  • Blue lunula (Blue half moons): Hepatolenticular degeneration, Wilson’s
  • Half and half nails (white proximally and red-brown distally): Uremia
  • Mee’s line (transverse white stria above lunula): Arsenic poisoning
  • Missing nail: Nail-patella syndrome (Nephrotic syndrome)

Note: At the end, ask patient to close hands and open hands to quickly assess mass movements of the hand. On flexion, tip of fingers must point to the schapoid tubercle.

Feel:

a. Skin (Temperature and sweating/Tenderness/Swelling):

• Warm and dry: Pyrexia
• Warm and moist: Thyrotoxicosis
• Cold and dry: Myxedema, Shock, Raynaud’s
• Cold and moist: Anxiety

b. Subcutaneous tissue:

• Rheumatoid nodules
• Dupuytren’s contracture (Palmar fascia)

c. Muscles and tendons:

• Bulk of muscles
• Tenosynovitis (Swelling over tendon sheath)
• Trigger finger (Thickening of flexor tendon)

d. Bones and joints:

• Hard swellings are bony (Osteophytes, tumors); soft swellings are synovitis
• Crepitus: Put index finger over fully extended fingers and ask to open and close the fingers (Osteoarthritis, fractures, tenosynovitis)

Special tests:

1. DeQuervain’s tenosynovitis: Finkelstein’s test (Thumb tucked in palm and ulnar deviation of wrist), Tenderness in radial styloid
2. Scaphoid fracture: Tenderness in Anatomical snuff box (EPL – EPB and APL)
   Carpal tunnel syndrome: Tinel’s test

Move:

a. Active movements:

• Fist and Open fist
• Power grip

b. Passive movements:

• Finger flexion-extension (note triggering)
• Prayer sign: Normal 90 degree extension
• Reverse prayer sign: Normal 90 degree flexion

Measure:

1. Motor function
   • Paper sign (Radial n.): Fully extend wrist and fingers
   • Scissor sign (Ulnar n.)
   • Stone sign (Median n.): Clench fist forcefully
   • OK sign (Anterior interosseous branch of median nerve): Supplies flexor pollicis longus and flexor digitorum porfundus
2. Sensory function
3. Circulation (Pulses)