Clinical Hand Exam

7/31/2019 Clinical Hand Exam

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CLINICAL HAND EXAM

Authors:

Jorma Mueller, MD

Moira Davenport, MD

Bellevue Hospital Center

New York University School of Medicine

New York, NY

Medical Editor:

Aaron Hexdall, MD

OVERVIEW

The goal of this video is to review a brief, but complete, clinical evaluation of the hand in the

context of acute injury.

This video will review:

1. Inspection and Palpation of the Hand

2. Sensory Evaluation

3. Motor Evaluation

4. Evaluation of the Tendons of the Hand

5. Evaluation of the Bones of the Hand

6. Vascular Evaluation of the Hand

Prior to examining the patient, a focused history must be obtained with attention to several

important factors. First, it is important to know the patients hand dominance, which is best

assessed by asking which hand they use to write. Next, ask about the timing and mechanism of

injury. This will give you an idea of what type of injury to expect and will often help to guide the

clinical examination.

Initial clues to nervous, bony, vascular, or tendon injury are often clearly visible. One should note

obvious injuries and the positioning of the hand as this information will guide your exam. Lastly,

comparison should always be made to the other uninjured hand, if possible.

INSPECTION AND PALPATION

Now we will briefly inspect the hand prior to beginning a more targeted clinical examination.

It is noteworthy that there is some confusion as to the best way to refer to the digits. The thumb is

the first digit, the index finger the second, the middle finger the third, the ring finger the fourth,

and the pinky is the fifth. The side with the first digit is referred to as the radial aspect of the

hand, while the side with the fifth digit is referred to as the ulnar aspect. Lastly, the anterior, or


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palm side of the hand, is referred to as the volar aspect, while the posterior side of the hand is

referred to as the dorsal aspect.

In this mock patient, there is clearly asymmetry between the hands with the right hand being held

in a pathologic position.

Other changes to evaluate for:

1. Swelling, especially of the fingers or the dorsum of the hand2. Deformity, including angulation of the fingers (this may only be obvious when you ask

the patient to move their fingers)

3. Discoloration4. Obvious wounds

Palpation of the hand is part of your general exam and can help to evaluate for:

1. Masses2. Areas of tenderness3. Crepitus4. Effusions5. Vascular compromise that might manifest itself as a difference in temperature6. Foreign bodies

SENSORY EVALUATION

In this section, we will demonstrate the sensory examination of the hand. First we will start by

reviewing the anatomy and distribution of cutaneous sensation in the hand.

Lets start with the sensory distribution of the median nerve, which we see traced out on the

anterior aspect of the left palm and highlighted in green on the right hand. It travels down the

radial side of the wrist passing under the flexor retinaculum of the carpal tunnel prior to enteringthe hand.

It gives off motor branches which will be discussed in the motor exam section. The sensory fibers

of the median nerve, divide providing cutaneous sensation from the palmar aspect of the hand

extending radially from the radial one half of the fourth digit to the first digit.

On the dorsal aspect of the hand, the median nerve provides sensation to the radial half of the

fourth digit, the third, second and first digits proximal to the distal interphalangeal joint.

The ulnar nerve travels down the ulnar aspect of the forearm. Within the forearm and as it

traverses the wrist to enter the hand, it travels with the ulnar artery, so when evaluating for injury

to one, injury to the other should always be considered. It enters the palm providing cutaneoussensation to the anterior and posterior aspects of the ulnar side of the hand and to the fourth and

fifth digits. Its territory extends to the ulnar half of the fourth digit only. In this example, the

sensory distribution of the ulnar nerve is highlighted in blue.

Cutaneous sensation to the posterior and lateral aspect of the hand is provided by a superficial

branch of the radial nerve. Its path is shown here and its distribution is highlighted in red. Of

note, the radial nerve travels very superficially, dividing just prior to traversing the snuffbox


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region defined by the tendons of extensor pollicis longus and brevis. Even superficial lacerations

to this area can cause significant sensory deficit.

There are no motor branches of the radial nerve in the hand.

Please note that each finger has two radial and two ulnar digital nerves; this convention refers to

the side of the finger on which they are found, not the nerve from which they arise.

We can now discuss testing cutaneous sensation in the hand. There are a variety of ways in which

to test cutaneous sensation and care must be taken as small deficits are easy to miss.

The sensory innervation of the median nerve is best tested on the palmar aspect of the hand here.

You can begin by assessing for light touch using a cotton-tip applicator; and as always,

comparing it with the other side. If the patient cannot feel light touch, a deficit is clearly present.

Two-point discrimination is a more sensitive test of sensory innervation. The minimum distance

at which a patient can discriminate two points should be recorded on both the non-injured hand

and the area in question.

Most patients are expected to easily discriminate two points at a distance of 6mm or greater.

The ulnar nerve is classically tested on the anterior aspect of the fifth digit. Again, light touch and

two-point discrimination are useful methods to determine whether there is a deficit.

The radial nerve is classically tested in the web space between the first and second digits. Light

touch and two-point discrimination are again evaluated.

For more distal injuries, the fingers should be evaluated individually. Care should be taken to

evaluate both the radial and ulnar aspect of each digit if nerve injury is suspected.

MOTOR EVALUATION

The range of motions possible with the human hand is amazing and the muscles that must

function together are numerous. This review focuses on the basic movements of the hand and the

nerves that are responsible for activating them, rather than the names of each of the individual

muscles.

We will briefly discuss the intrinsic muscles of the hand and then the extrinsic muscles. Intrinsic

muscles are contained entirely within the hand while the extrinsic muscles are responsible for

hand motion but originate in the forearm and exert their actions through lengthy tendons.

The thenar muscles are the fleshy pad at the base of the first digit and are responsible for

abduction, opposition, and flexion of the first digit at the metacarpophalangeal joint.

The muscles responsible for these actions are innervated by the median nerve. There is another

muscle in the thenar group that merits individual attention. Adductor pollicis is contained in this

group of muscles and is responsible for adduction of the first digit.

A branch of the ulnar nerve is responsible for this action. Laceration of the ulnar nerve, or that

branch, will compromise adduction and leave the first digit in abduction.


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Here, our model demonstrates the hand position after an ulnar nerve injury.

The thenar muscles can be grossly tested by having the patient touch their first digit to the

thumbnail of their fifth digit and pulling; asking them to maintain that position while resistance is

applied. Alternatively, the hand can be laid flat on a table and the thumb brought to vertical 90

degrees against resistance.

Testing adduction of the thumb which as previously mentioned, is controlled by a branch of the

ulnar nerve, can be accomplished by having the patient hold a piece of paper or cloth in their

hand between their first and second digits. Flexion of the thumb at the IP joint indicates

compromise of the adductor pollicis and is known as Froments sign.

The hypothenar muscles are the fleshy pad at the base of the fifth digit. They are all innervated by

the ulnar nerve. They are responsible for opposition, abduction, and flexion of the fifth digit.

The hypothenar muscles can be tested simply be asking the patient to move their smallest digit

away from the hand against resistance.

Lumbricals are muscles between the flexor tendons on the palmar aspect of the hand. They areresponsible for keystroke type motionflexion at the metacarpophalangeal joints and

extension at the proximal interphalangeal joint.

The second and third are innervated by the median nerve, while the fourth and fifth are innervated

by branches of the ulnar nerve.

The interosseous muscles are contained in the palm and are responsible for abduction and

adduction of the digits.

The interosseous muscles can be tested by having the patient abduct their fingers against

resistance.

EVALUATION OF THE TENDONS OF THE HAND

The extrinsic muscles originate in the forearm and have tendons that travel into the hand by

traversing the wrist.

The tendons of the flexor digitorum profundus (FDP) pass under the flexor retinaculum and are

contained here in the carpal tunnel. They are responsible for flexion of the digits at the distal

interphalangeal joint. The tendon can be tested by placing the hand on a flat surface,

immobilizing the middle phalanx with a pen, and asking the patient to flex the finger at the distal

interphalangeal joint.

The flexor digitorum superficialis (FDS) follows the same path as the FDP tendons but runssuperficial to them, bifurcates, and inserts at the level of the middle phalanx.

It is responsible for flexion of the digit at the level of the proximal interphalangeal joint. The

tendons of the FDP pass through the bifurcated FDS to insert on the distal phalanx.

The FDS can be tested by having the patient lay their hand flat on a surface, immobilize the

proximal phalanx, and flex the fingers at the level of the proximal interphalangeal joint.


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Flexion of the first digit at the interphalangeal joint is performed by the flexor policis longus and

can be tested in a similar fashion to the flexor digitorum profundus.

Extension of the hand digits is performed by several muscles with their bodies in the forearm that

traverse the dorsal aspect of the wrist and insert onto the digits.

Extensor digiti minimi is responsible for extension of the fifth digit. It can be tested by having thepatient lie their hand flat on a surface and hyperextend the fifth digit.

The extensor digitorum tendons extend digits two through five. The hand can be laid flat again on

a surface and the tendon of each finger tested by having the patient hyperextend the digits against

resistance.

Extension of the second finger is also performed by extensor indicis, which can be tested in a

similar fashion to extensor digiti minimi.

Extension of the first digit is controlled by two muscles, extensor pollicis longus and brevis. The

path of these two tendons defines the anatomical snuffbox which contains the radial artery and

the scaphoid bone of the wrist. Extension of the thumb at the interphalangeal joint and themetacarpophalangeal joint can be tested separately against resistance.

Discussion of the complete scope of tendinous, or ligamentous injuries in the hand, is beyond the

scope of this introductory review. We will touch on a few common injuries and the tests used to

identify them.

The ulnar collateral ligament at the base of the first metacarpophalgeal joint is responsible

for stabilizing the joint in the face of radial stress. It may be disrupted with hyperextension

injuries.

To test to see if it has been disrupted, have the patient hold the hand with the first digit

completely extended and compare it to the contra-lateral side noting restriction or laxity.

Repeat the test with the digit held in 30 degrees of flexion. Increased laxity is indicative of an

injury to the ulnar collateral ligament, colloquially referred to as a Game Keepers thumb.

Stenosing tenosynovitis, also know as Trigger finger, is an inability to extend a flexed finger. It

occurs when one of the flexor tendons does not slide smoothly through the pulleys at the

metacapophalangeal joint. Patients will present with a flexed finger that must be forcibly

extended using the other hand.

Sometimes, a lump of fibrous tissue is palpable in the region of metacarpophalangeal joint when a

trigger finger is present, thus reinforcing the diagnosis.

DeQuervains tenosynovitis results from inflammation of the extensor and abductor tendons of

the first digit. It can be tested for with Finkelsteins test. The hand is positioned as shown, with

the first digit under the other four. The examiner then provides ulnar deviation at the wrist. The

Finkelsteins test is positive when it produces pain.

Swan neck deformity and Boutiniere deformity result from a breakdown in the tendinous

apparatus that runs the length of the digits. These two deformities occur most commonly post-

traumatically or in the context of advanced rheumatoid arthritis.


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The Swan neck deformity occurs when these tendons sublux dorsally resulting in hyper-

extension of the proximal interphalangeal joint with partial flexion at the distal interpahlangeal

joint.

A Boutiniere deformity is present when the central slip of the ligamentous apparatus has ruptured.

The proximal interphalangeal joint is hence held in flexion, often with the distal interphalangealjoint held in extension.

Mallet finger results from disruption of the extensor tendon insertion at the distal phalanx. Blunt

trauma or lacerations are the most common mechanisms. The finger is typically held in extension,

with flexion at the distal interphalangeal joint.

EVALUATION OF THE BONES OF THE HAND

The bony anatomy of the hand proper is relatively simple and evaluation for bony pathology, a

fracture for example, depends in large part upon the mechanism and the presence of bony

tenderness. A full discussion of the evaluation of the wrist is beyond the scope of this section, so

we will discuss the bones of the hand and wrist together.

There are eight bones in the wrist. Many clinicians find it difficult to remember them in order and

use a pneumonic device. We suggest:

Sad: Scaphoid

Lonely: Lunate

Travis: Triquetrum

Pushes: Pisiform

His: Hamate

Cart: Capitate

Through: Trapezoid

Texas: Trapezium

It is important to recognize the bones of the wrist on an A/P radiograph. Note here:

Sad: Scaphoid

Lonely: Lunate

Travis: Triquetrum

Pushes: Pisiform

His: Hamate

Cart: Capitate

Through: Trapezoid

Texas: Trapezium

Special attention should be paid to the base of the thumb, scaphoid bone and the distal radius, as

these are common sites of injury in falls on an outstretched hand.

The tubercle of the scaphoid is easily palpated on our live model. Note that it is located

approximately in the anatomic snuffbox. Tenderness with palpation of the snuffbox suggests a

scaphoid fracture, regardless of the radiographic appearance of the scaphoid.

Axial loading of the first digit is a more specific test for pathology at the carpometacarpal joint.


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There are five metacarpal bones that sit in the palm and articulate with the digits proper at the

metacarpophalangeal joints. Like the digits, they are referred to by number. The rest of the bony

structures should be palpated. Strong suspicion for fracture based on mechanism or the presence

of point tenderness on exam merits a radiograph.

Common mechanisms consistent with fractures include crush injuries and blunt trauma frompunching. Pain, edema, deformity and discoloration are common signs of fracture. The hand

should be examined in both extension and flexion, specifically evaluating for fracture associated

rotational deformities. Some proximal phalanx fractures appear normal on extension, but may be

more easily appreciated on flexion. Here, a rotational deformity of the fifth digit is simulated.

Note the asymmetry of the finger nails.

Another common injury is the fracture of the metaphysic of the fourth or fifth metacarpal, the so-

called Boxers fracture. This injury is characterized by loss of the prominence of the metacarpal

heads and tenderness.

VASCULAR EVALUATION OF THE HAND

Lets discuss the vascular supply to the hand. Looking at the anterior aspect on the radial side the

radial artery supplies the hand. From the ulnar side the ulnar artery traverses the wrist and

supplies the hand as well. Together they form superficial and deep palmar arches. Here, the deep

palmar arch is represented by dashed lines. These arches then send arterial blood to the digits.

Each finger has two radial and two ulnar digital arteries that supply it. As with the digital nerves,

the names of the digital arteries refer not to the artery from which they are derived but to which

side of the finger they are located. The arteries on the palmar aspect deliver significantly more

blood than those on the dorsal aspect.

Looking at the finger head-on, the digital arteries are located at ten, two, four and eight oclock.

On the anterior aspect of the wrist, the radial and ulnar arteries can be palpated as demonstrated.Alternatively, the radial artery can sometimes be palpated in the anatomical snuffbox.

The Allen test is performed to evaluate for vascular patency in the setting of an injury or prior to

an arterial puncture. All of the digits are flexed which will empty the hand of blood. Both the

radial and ulnar arteries are occluded by the examiner. The hand is then gently opened. As you

can see, the hand appears pale.

The ulnar artery is then released and the hand evaluated for color change. Capillary refill should

occur in less than five seconds. The test is then repeated on the radial artery and the time noted as

well. Prolonged filling times are consistent with a vascular injury or thrombus.

Evaluating the vascular supply to specific fingers can be a little trickier. The color of the digit inquestion is often a clue. If it is blue or cold, that is an indication that it is not receiving adequate

blood supply. Capillary refill is also clinically useful way to evaluate whether a digit is

adequately perfused.

Capillary refill is generally brisk and occurs in less than two seconds. Prolonged refill times are

consistent with vascular compromise. The Allen test, similar to the one used to evaluate for radial

and ulnar artery patency can also be applied to the digits. The digit in question is flexed, thereby


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exsanguinating it of blood. The clinician occludes the radial and ulnar digital arteries at the base

of the digit. Release of either artery should result in brisk capillary refill to the digit.

Finally, a Doppler ultrasound device can be used to evaluate for vascular patency. A normal,

triphasic flow should be heard over the radial, ulnar and digital arteries.

Documents

Clinical Hand Exam