Examination of the hand C Snyckers 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 – – – 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 – 1 st 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 • • • 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 – – Flexion finger creases – joints Palmar skin tightly adhered for grip (palmar aponeurosis) Distal & proximal palmar creases Thenar/ hypothenar eminences • Check – – – Fingertip abscess - felon Loss of creases and tightness – infection Contracture of the palmar aponeurosis – Dupuytren’s Cardinal signs of Kanavel – septic tenosynovitis • • 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 • 1 st 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

v. Finkelstein Quervain’s v. Allen’s test – de test – vascular supply of the hand