Year 2 MBChB

Clinical Skills

Examination of the hands & nails

Written by: Clinical Skills Lecturer Team

Reviewed by: Dr Stuart N Cohen, Specialty Lead for Dermatology

2

Learning objectives

• To understand the basic principles of inspection of the hands and nails.

• To demonstrate an understanding of linking hand and nail signs to a differential diagnosis.

Theory and background

Information from examination of the patient should always be interpreted in conjunction with the history. Apparent

indicators of disease may turn out to be congenital or secondary to trauma. It is important to know whether changes are

acute or chronic, and whether they are stable or evolving. Inspection is a key component of physical examination. In the

hands and nails, many different findings can occur, which can indicate a wide array of diagnoses. Some are primary skin or

nail conditions, whilst others are secondary to underlying disease processes.

Please be aware that this study guide is not exhaustive. It is designed to give you an overview of some findings that you may

encounter whilst performing an examination of a patient’s hands and nails. Further reading may be needed to help you to

understand why certain disease processes may cause different signs on the hands and nails to develop.

Indications

Inspecting the hands and nails can be a key component of clinical examinations, for example:

o Respiratory exam

o Gastrointestinal exam

o Thyroid exam

o Cardiovascular exam

o Neurological exams

o Musculoskeletal exams

o Dermatological exams

Procedure

Patient safety

On first meeting a patient, introduce yourself, and confirm that you have the correct patient by name and date of

birth; if available please check this with the wristband and written documentation, confirming the patients NHS /

hospital number or first line of address.

Check the patient’s allergy status, being aware of the equipment you will be using in your examination. Ensure

that the procedure is explained to the patient in terms that they understand, gain informed consent and ensure

that you are supervised, with a chaperone available as appropriate. Don personal protective equipment as

required, especially if you are likely to come into contact with bodily fluids.

Be aware of hand hygiene and preventing the spread of disease, WHO (2018) http://www.who.int/infection-

prevention/tools/hand-hygiene/en/

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Inspection of the hands

Observe for:

Movement

Please be aware that some patients will be unable to move how you wish them to, due to frailty or underlying

medical conditions. Ensure that you allow for this during your examination and do not cause the patient distress

or discomfort.

Ask the patient to raise their hands out in front of them with their palms facing the floor. You may see:

o Tremor (this may be due to a number of reasons, such as alcohol withdrawal, parkinsonism, thyrotoxicosis

or medication)

Then ask the patient to hold out their arms with their wrists extended to check for:

o Metabolic flap (this may be due to a neurological cause or increased CO2 retention)

o Asterixis – coarse flapping tremor (occurs with hepatic encephalopathy)

Skin texture

Make sure that you are assessing the dorsal and palmar aspect of the hands (front and back), and ensure you are

comparing both sides to each other. Don’t forget to ask the patient if anything you note is new or old for them; if

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they have any scars ask them what caused them. This may aid you in your diagnosis. When examining the hands

you may find:

o A rash such as dermatitis

o Scarring

o Swelling / thickening

o Callouses (a thickening or hardened part of the skin)

o Loss of muscle bulk (wasting)

o Changes in colour

o Clammy palms

Skin colour

o Peripheral cyanosis (this could be due to lack of oxygen, or they could be cold or have poor circulation)

o Pale skin creases (if the skin creases are as pale as the surrounding palms, this may be an indicator of

anaemia)

o Palmar erythema (this may be normal for the patient; specific causes include pregnancy, chronic liver

disease or thyrotoxicosis)

o Tobacco staining of the fingers from smoking

Hand and Nail changes

Fig.1

Dupuytren’s contracture – This is a thickening of the

palmar fascia, (the band or sheet of connective tissue,

primarily collagen, beneath the skin that attaches,

stabilises, encloses and separates muscle and other

internal structures), causing fixed flexed deformity and

usually affects the little and ring fingers. Usually starts as

small hard nodules on the palmar surface under the

skin. This is often familial but may be caused by

alcoholism or other factors.

http://meded.ucsd.edu/clinicalimg/browse.htm

Charlie Goldberg M.D.

Fig.2

Peripheral cyanosis – Distal bluish discolouration which

can be associated with hypoperfusion, environmental

factors i.e. cold temperature or the patient may have a

cardiorespiratory condition causing hypoxia.

By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=17978808

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Fig.3

Raynaud’s phenomenon – This is digital ischaemia which is

induced by cold or emotional stress. It has three phases,

pallor, cyanosis and redness. It may be primary and idiopathic

(Raynaud’s disease), or secondary (Raynaud’s syndrome) due

to factors such as malignancy, connective tissue syndromes

(e.g. systemic lupus erythematosus [SLE]), atherosclerosis (a

build-up of plaque inside the arteries) or it may be drug

related.

Kindly anonymously donated to the Clinical Skills Team

Fig.4

Palmar erythema – Redness of the palmar skin.

This may be normal for the patient or can be due

to excess oestrogen associated with reduced

hepatic breakdown of hormones. It is also

common in pregnancy or when malabsorption of

hormones is reduced in the presence of liver

damage.

Gastrointestinal system Rochford, Andrew, Hutchison's Clinical Methods, 14, 241-271 Copyright © 2018 © 2018 Elsevier Ltd. All rights reserved

Fig.5

Clubbing – This is where there is a loss of the angle

between the nail bed and the fingernail. The exact

cause of fingernail clubbing is unknown. Whilst it

may be seen in healthy individuals as a congenital

variant, associated chronic conditions include: lung

cancer, chronic lung disease, cyanotic heart

disease, cirrhosis of the liver and inflammatory

bowel disease.

General aspects of examination Dover, Anna R, Macleod's Clinical Examination, 3, 19-36

Copyright © 2018 © 2018 Elsevier Ltd. All rights reserved.

6

Fig.6

Koilonychia – A rare finding of spoon-shaped nails,

which may be a normal variant or caused by chronic

iron deficiency anaemia and occasionally other

factors.

General patient examination and differential diagnosis Drake, William M., Hutchison's Clinical Methods, 2, 15-29 Copyright © 2018 © 2018 Elsevier Ltd. All rights reserved

Fig.7

Lindsay’s nails (half-and-half nails) - Distal red or brown band on

the nails. The proximal nails may be white or pink. This mostly

occurs in the setting of chronic renal failure. Again, this is an

occasional finding but a useful clue if noted on examination.

http://health.allrefer.com/pictures-images/half-and-half-nails.html

Fig.8

Leukonychia - Whitening of the nails, which can

appear as linear or be transverse. True leukonychia

stays white when pressure is applied to the nail bed.

This may be a clinical sign of hypoalbuminemia (low

albumin), which can be seen in nephrotic syndrome (a

form of kidney disease), liver failure and protein

malabsorption.

General patient examination and differential diagnosis Drake, William M., Hutchison's Clinical Methods, 2, 15-29 Copyright © 2018 © 2018 Elsevier Ltd. All rights reserved

7

Fig.9

Beau’s lines - These are deep, grooved lines that run

from side to side on the fingernails or toenails. They

may look like indentations or ridges in the nail plate.

They can be due to cessation of nail growth due to

recent severe illness or chemotherapy but may also

be due to trauma to the nail.

Skin, Hair, and Nails Ball, Jane W., DrPH, RN, CPNP, Seidel's Guide to Physical Examination, Chapter 9, 131-183

Copyright © 2019 Copyright © 2019 by Elsevier, Inc. All rights reserved.

Fig.10

Splinter haemorrhages - Asymmetrical,

splinter-like lesions; the most common cause is

trauma to the individual nail bed. Clinical causes

may include infective endocarditis or vasculitis.

Caused when blood leaks or swells from small

vessels that run up and down the nail bed.

Fig. 11

Janeway’s lesions – Non-tender, haemorrhagic macules of a

few millimetres in diameter. They can be found on the palms

and soles. They are rare but may be indicative of infective

endocarditis, SLE or gonococcaemia (gonorrhoea).

Osler’s nodes - Painful, red, raised lesions found

typically on the fingers and or toes; pain will usually

precede the development of an Osler’s node. The cause

is still subject to debate. They are associated with a

number of conditions, but especially infective

endocarditis.

Blood Vessels Klatt, Edward C., MD, Robbins and Cotran Atlas of Pathology, Chapter 1, 1-26.e3

Copyright © 2015 Copyright © 2015, 2010, 2006 by Saunders, an imprint of Elsevier Inc

Both Janeway’s lesions and Osler’s nodes are very similar in appearance and may be found in conjunction.

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Fig.12

Pitting – Small depressions in the nail plate. They are most

commonly seen in psoriasis, but are also a feature of other

skin conditions such as eczema, alopecia areata and lichen

planus. They are caused by defective development of the

layers of the superficial nail plate.

http://www.dermatlas.org/derm/result.cfm?Diagnosis=-946037564

Fig.13

Oncholyosis – This is where the free edge of the

nail separates from the underlying nail bed. It can

be caused by psoriasis, fungal infections or

thyrotoxicosis.

Fig.14

Onychomycosis – This is infection of the nail plate

with dermatophyte fungus. It can cause white,

yellowish, brown or sometimes dark discoloration

of the nail, as well as onycholysis. Toe-nails often

become markedly thickened.

Fungal Diseases Bolognia, Jean L., MD, Dermatology Essentials, 64, 613-633 Copyright © 2014 © 2014, Elsevier Inc. All rights reserved

9

Fig.15

Contact dermatitis – this is divided into allergic contact

dermatitis (ACD), in which the eruption is due to type IV

(delayed) hypersensitivity, and irritant contact dermatitis

(ICD), where environmental insults – such as repeated

exposure to water or irritant chemicals – exceed the

skin’s barrier defences. Both present with dryness,

erythema and scaling. Vesiculation (blistering) may occur

in ACD and itching can be severe; fissures are more likely

to be seen in ICD (or palmar psoriasis), where soreness is

often more marked. ICD can exacerbate any other form

of hand dermatitis.

Eczema – Basic principles and irritant contact dermatitis Gawkrodger, David J., DSc MD FRCP FRCPE, Dermatology: An Illustrated Colour Text, 17, 34-35.e1

Copyright © 2017 © 2017 Elsevier Ltd. All rights reserved

Fig.16

Atopic dermatitis (atopic eczema) – Commonly familial and

more prevalent in children, usually presents as itchy, dry,

cracked sore or red skin especially on flexor aspects of the

skin (back of elbows and knees). It can be widespread and

frequently affects the hands. There is often an irritant

component, from wet-work or frequent handwashing, and

exposure to soaps or detergents.

Image kindly donated to the clinical skills department

Fig.17

Psoriasis – A chronic, immune-mediated inflammatory

skin disorder. It is a common papulosquamous condition

characterised by well-demarcated, erythematous

plaques with overlying thick, silvery scale. Psoriasis

occurs at all ages and is characterised by chronic and

relapsing episodes. There are varying subtypes. It is most

commonly found on the extensor aspects of the elbows

and knees, scalp, periumbilical region, lumbosacral

region and intergluteal cleft. There is also a

palmoplantar variant (i.e. affecting the palms and soles)

which can occur in isolation or alongside more

widespread psoriasis.

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http://www.danderm.dk/atlas/5-32-4.html

Fig.18

Paronychia (whitlow) – This is an infection of

the skin just next to the nail (the nail-fold). The

skin is usually red, swollen and tender; there

may be a visible collection of pus that requires

lancing. Causes include bacteria and Candida

(a type of yeast). This is more common in

patients who bite their nails or have had some

trauma to the area.

Skin disorders Henry, Michael M, MB FRCS, Clinical Surgery, 39, 703-720 Copyright © 2012 © 2012 Elsevier Ltd. All rights reserved.

Fig. 19

Acropachy – A rare and severe autoimmune

dermopathy associated with Graves’

hyperthyroidism, where there is soft tissue swelling

of the hands and feet that in turn causes clubbing of

the fingers and toes. There is also periostitis

(inflammation of the periosteum which overlies

bone), which can lead to new bone formation.

General aspects of examination Dover, Anna R, Macleod's Clinical Examination, 3, 19-36

Copyright © 2018 © 2018 Elsevier Ltd. All rights reserved Fig.20

Nicotine tar staining – Tobacco stains on a heavy cigarette smoker,

primarily on the second and third finger.

By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=9444890

Commented [SNC1]: This is a more appropriate picture of psoriasis. D@nderm images are approved for educational use without permission. I’m afraid I’ve messed up the spacing though, here and below – hopefully you can fix it.

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fig.21

Muscle wasting (atrophy) – Can

be due to a lower motor neurone

lesion, but may be seen in

patients with a long-standing

upper motor neurone lesion. Can

also be caused by muscular

dystrophy, motor neurone

disease and trauma. Can result

from the muscles in the area not

being used (disuse atrophy).

(Note that in the image, the

tendons in the left hand appear

more pronounced than the right

due to muscle wasting).

The neurological examination: The peripheral nervous system Talley, Nicholas J, MBBS (Hons)(NSW), MD (NSW), PhD (Syd), MMedSci (Clin Epi)(Newc.), FRACP, FAFPHM, FAHMS, FRCP (Lond. & Edin.), FACP, FACG, AGAF, FAMS, FRCPI (Hon), Talley & O'Connor's Clinical Examination, Chapter 34, 548-579 Copyright © 2018 ©2018 Elsevier Australia. 1st edition ©1988, 2nd edition ©1992, 3rd edition ©1996, 4th edition ©2001, 5th edition ©2006, 6th edition ©2010, 7th edition ©2014 Elsevier Australia

Fig.22

Rheumatoid arthritis – An autoimmune disease in which the

immune system damages the cells that line the joints. It frequently

affects the distal interphalangeal and proximal interphalangeal

joints. It causes pain, swelling and stiffness, and over time leads to

damage to the joints, cartilage and nearby bone. It can result in

deformity, and ulnar deviation of the hand.

Other Rheumatologic Diseases Bolognia, Jean L., MD, Dermatology Essentials, 37, 329-335

Copyright © 2014 © 2014, Elsevier Inc. All rights reserved.

Commented [SNC2]: I’d never heard of Lou Gehrig!

Commented [SNC3]: Stroke deleted as this is covered by upper motor neurone lesion

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Fig.23

Osteoarthritis – This is the most common

type of joint disease, in which the protective

cartilage on the ends of the bones breaks

down causing pain, swelling and restriction

of movement. In the hands, the DIP joints are

most commonly affected. Bony growths may

occur. Many risk factors are recognised in

osteoarthritis, including age, repetitive use

of joints, previous inflammatory conditions

such as rheumatoid arthritis or gout, and

bony trauma including surgery.

Osteoarthritis Aitken, Marc Joseph, MBChB, MRCP (UK), Crash Course Rheumatology and Orthopaedics, 11, 67-71 Copyright © 2019 © 2019, Elsevier Limited. All rights reserved.

Some other signs you may see in patients with Rheumatoid / Osteoarthritis Arthritis

Rheumatoid Arthritis and Osteoarthritis

Hawkins, Tina, Clinical Pharmacy and Therapeutics, 54, 923-948 Typical ulnar deviation, swan neck and boutonnière deformities. Copyright © 2019 © 2019, Elsevier Limited. All rights reserved.

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Quincke’s sign – This occurs when there is aortic insufficiency. For example, in aortic regurgitation where blood

flows back into a dilated left ventricle it causes a decrease in diastolic pressure and a subsequent increase in

stroke volume. This manifests as a blanching and flushing of the nail beds. Follow the below link to watch a

video of how this appears.

https://www.youtube.com/watch?v=V7u3vaKEDCI

Quick guide to hands and nail assessment

Hand or Nail Changes Description Differential diagnosis

Dupuytren’s contraction Fig.1

Flexed fixed deformity Thickening of the palmar fascia,

may be hereditary or be due to

chronic liver disease

Peripheral cyanosis Fig.2

Discoloration to the peripheries May be due to cold, hypoperfusion

or cardiovascular disease

Raynaud’s phenomenon Fig.3

Discoloration to the digits and cold

to the touch

Can be idiopathic or due to a

secondary disease process

Palmar erythema Fig.4

Redness of the palms May be genetic, or due to chronic

liver disease or pregnancy

Clubbing Fig.5

Loss of the nail angle Multiple disease processes may

cause this; may also be normal for

the patient

Koilonychia Fig.6

Spoon shaped depression of the

nail plate

Iron deficiency anaemia

Lindsay’s nails Fig.7

White or brown half-and-half nails Chronic kidney disease

Leukonychia Fig.8

White spots, ridges or a complete

discoloration of the nail

Hypoalbuminemia

Beau’s Lines Fig.9

Transverse grooves Can be due to any severe systemic

illness that may affect the growth

of the nails, or trauma

Splinter haemorrhages Fig.10

Small red streaks that lie

longitudinally in the nail bed

Trauma, infective endocarditis or

vasculitis

Janeway’s lesions Fig.11

Painless blanching macules on the

palms of the thenar/hypothenar

eminences

May be caused by infective

endocarditis, systemic lupus

erythematosus (SLE) or

gonococcaemia (gonorrhoea)

Osler’s nodes Painful raised erythematous

lesions, typically found on the

pads of the fingers

May be due to infective

endocarditis and having an

immune complex disposition

Pitting Fig.12

Fine or coarse indentations in the

nail bed

Can be due to a number of

conditions such as alopecia areata,

psoriasis, eczema or lichen planus

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Onycholysis Fig.13

Separation of the nail plate from

the underlying nail bed

Usually due to psoriasis or fungus

Onychomycosis Fig.14

Thickening and discoloration of

the nail plate

Fungal infection

Atopic eczema Fig.15

Dry, red, itchy and flaky skin Usually a familial tendency;

exacerbated by exposure to water

or irritant chemicals

Contact dermatitis Fig 16

It usually involves itchy, dry, red,

flaky skin. The skin may also

blister, ooze or flake off

Dermatitis is a common condition

that can be caused by many

different factors

Psoriasis Fig.17

Well-demarcated, erythematous,

scaly plaques

A common, chronic, immune-

mediated inflammatory skin

disorder

Paronychia Fig.18

Red, swollen and often pus-filled

area around the nail bed

Usually caused by a localised

infection

Acropachy Fig.19

Soft tissue swelling of the hands

that causes finger clubbing and

periosteal reaction of the

extremities

Associated with Graves’ disease

Nicotine tar staining Fig.20

Tobacco stains Suggests heavy smoking

Muscle wasting Fig.21

Wasting of the muscles of the

hands

May be due to a neurological

lesions, muscular dystrophy,

motor neurone disease, stroke or

trauma.

Rheumatoid arthritis Fig.22

Pain, swelling, weakness and

deformities

Caused by the body’s own immune

system attacking it

Osteoarthritis Fig.23

Pain, swelling, stiffness and bony

growths

Caused by the protective cartilage

on the ends of the bones breaking

down

Quincke’s sign A pulsating flicker in the nail beds This is due to aortic insufficiency

Further resources

The British association of Dermatologists

http://www.bad.org.uk/

British Hair and Nail society

https://bhns.org.uk/

Patient info

https://patient.info/

DermNet NZ

https://www.dermnetnz.org/