11/13/24, 7\:05 PM Guide | Hand examination

Hand examination

Table of contents
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Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
y o u r h a n d s a n d w r i s t s . T h e e x a m i n a t i o n w i l l i n v o l v e m e
d o s o m e m o v e m e n t s .
"
Gain consent to proceed with the examination.
Adequately expose the patient’s hands, wrist and elbows.
Position the patient seated with their hands on a pillow.
Ask the patient if they have any pain before proceeding with the clinical examination.

Look

=

General inspection

Clinical signs
Perform a brief general inspection of the patient, looking for signs suggestive of underlying pathology\:
Scars\: may provide clues regarding previous upper limb surgery.
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Wasting of muscles\: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron lesion.
Objects or equipment
clinical status\:
Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
Aids and adaptations\: splints are often used to manage hand and wrist pathology.
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient’s recent
medications (e.g. analgesia).

Close inspection of the hand

Dorsal aspect of the hand
With the patient's palms facing down, inspect the dorsum of each hand for signs suggestive of underlying pathology\:
Hand posture\: note any abnormalities of hand posture which may indicate underlying pathology (e.g. Dupuytren's
contracture, ulnar deviation secondary to rheumatoid arthritis).
Scars\: inspect for evidence of scars which may indicate previous surgery or trauma.
Swelling\: note any areas of swelling, by comparing the hands and the wrists.
Skin colour\: erythema of the soft tissue may indicate cellulitis or joint sepsis
Bouchard's nodes\: occur at the proximal interphalangeal joints (PIPJ) and are associated with osteoarthritis.
Heberden’s nodes\: occur at the distal interphalangeal joints (DIPJ) and are associated with osteoarthritis.
Swan neck deformity\: occurs at the distal interphalangeal joint (DIPJ) with clinical features including DIPJ
hyperextension. Swan neck deformity is typically associated with rheumatoid arthritis.
Z-thumb\: hyperextension of the interphalangeal joint, in addition to
metacarpophalangeal joint (MCPJ). Z-thumb is associated with rheumatoid arthritis.
Boutonnières deformity\: PIPJ
Skin thinning or bruising\: can be associated with long-term steroid use (e.g. common in patients with active in
arthritis).
Psoriatic plaques\: salmon coloured plaques with a silvery scale. Patients who have psoriasis are at signi
risk of developing psoriatic arthritis.
Muscle wasting\: can occur secondary to chronic joint pathology or lower motor neuron lesions (e.g. median nerve damage
secondary to carpal tunnel syndrome).
Splinter haemorrhages\: a longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include
local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease.
Nail pitting and onycholysis\: associated with psoriasis and psoriatic arthritis.
Palmar aspect of the hand
With the patient's palms facing up, inspect each hand for signs suggestive of underlying pathology\:
Hand posture\: note any evidence of abnormal hand posture (e.g. clawed hand secondary to Dupuytren's contracture).
Scars\: inspect for evidence of scars which may indicate previous surgery or trauma (e.g. carpal tunnel surgery).
Janeway lesions\: non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms (and
soles). Janeway lesions are typically associated with infective endocarditis.
Osler's nodes\: red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the
are typically associated with infective endocarditis.
Swelling\: note any areas of swelling, by comparing the hands and the wrists.
Dupuytren’s contracture involves thickening of the palmar fascia, resulting in the development of cords of palmar fascia
which eventually cause contracture deformities of the
Thenar/hypothenar wasting\: isolated wasting of the thenar eminence is suggestive of median nerve damage (e.g. carpal
tunnel syndrome).
Elbows\: inspect for evidence of psoriatic plaques or rheumatoid nodules.
https\://app.geekymedics.com/osce-guides/clinical-examination/hand-examination/ 2/1011/13/24, 7\:05 PM Guide | Hand examination
Inspect the dorsum of the hand
Types of arthritis
Osteoarthritis (OA) is the most common form of arthritis and is characterised by joint pain worsened with activity,
localised loss of cartilage, remodelling of adjacent bone and associated in
include swellings at the distal interphalangeal joints (Heberden's nodes) and proximal interphalangeal joints (Bouchard's
nodes) which represent osteophyte formation. There is often associated crepitus and reduced range of joint movement.
Rheumatoid arthritis (RA) is an autoimmune disease characterised by in
tissue destruction and a variety of extra-articular features (e.g. rheumatoid nodules, scleritis, nail fold infarcts and
peripheral nerve entrapment). Patients typically experience joint pain (present even at rest), joint swelling and morning
joint sti
interphalangeal joints, metacarpophalangeal joints and wrist joints. Other features of RA in the hands include muscle
wasting, ulnar deviation, swan neck deformity, Boutonnière's deformity and Z-thumb deformity.
Psoriatic arthritis is an autoimmune disease associated with psoriasis that is characterised by in
and the surrounding tendons. Typical clinical features in the hands include joint swelling, joint pain and dactylitis (swelling
of whole digits).

Feel

Palms up

Temperature
Assess and compare the temperature of the joints of the hand and elbow using the back of your hands.
Increased temperature of a joint, particularly if also associated with swelling and tenderness may indicate septic arthritis or
in
Radial and ulnar pulse
Palpate the radial and ulnar pulse to con
Thenar and hypothenar eminence bulk
Palpate the muscle bulk of the thenar and hypothenar eminences\: wasting can be caused by disuse atrophy as well as lower
motor neuron lesions (e.g. ulnar and median nerve).
https\://app.geekymedics.com/osce-guides/clinical-examination/hand-examination/ 3/1011/13/24, 7\:05 PM Guide | Hand examination
Palmar thickening
Support the patient’s hand and palpate the palm to detect the typical bands of thickened palmar fascia associated with
Dupuytren's contracture.
Median and ulnar nerve sensation
1. Assess median nerve sensation over the thenar eminence and index
2. Assess ulnar nerve sensation over the hypothenar eminence and little
Assess & compare joint temperature

Palms down (dorsum)

Radial nerve sensation
Assess radial nerve sensation over the
Temperature
Assess and compare the temperature of the joints on the dorsal aspect of the hand (e.g. metacarpophalangeal joints) and
elbow using the back of your hands.
Metacarpophalangeal joint squeeze
Gently squeeze across the metacarpophalangeal (MCP) joints and observe for verbal and non-verbal signs of discomfort.
Tenderness is suggestive of active in
Bimanual joint palpation
Bimanually palpate the joints of the hand, assessing and comparing for tenderness, irregularities and warmth\:
Metacarpophalangeal joint (MCPJ)
Proximal interphalangeal joint (PIPJ)
Distal interphalangeal joint (DIPJ)
Carpometacarpal joint (CMCJ) of the thumb (squaring of the joint is associated with OA)
Anatomical snu
Palpate the anatomical snu
Bimanual wrist palpation
Palpate the wrists for evidence of joint line irregularities or tenderness.

Elbows

Elbow palpation
https\://app.geekymedics.com/osce-guides/clinical-examination/hand-examination/ 4/1011/13/24, 7\:05 PM Guide | Hand examination
Palpate the patient's arm along the ulnar border to the elbow and note any tenderness, rheumatoid nodules or psoriatic
plaques.
Assess radial nerve sensation
Scaphoid fracture
The scaphoid is the largest bone in the proximal row of carpal bones and is also the most
commonly fractured. It often occurs due to a fall on an outstretched hand. As a result of the poor blood supply to the
scaphoid, fractures can be slow to heal and avascular necrosis of the proximal fragment of the scaphoid can occur.
Tenderness in the anatomical snu

Move

The joints of the hand and wrist should be assessed and compared.
If the patient is known to have an issue with a particular hand, you should assess the 'normal' hand

Active movement

Active movement refers to a movement performed independently by the patient. Ask the patient to carry out a sequence of
active movements to assess the function of various joints. As the patient performs each movement, note any restrictions in the
range of the joint's movement and also look for signs of discomfort.
It's important to clearly explain and demonstrate each movement you expect the patient to perform to aid understanding.
Finger extension
Instructions\: " O p e n y o u r
"
Finger
Instructions\: " M a k e a
"
Wrist extension
Normal range of movement\: 90º
Instructions\: " P u t t h e p a l m s o f y o u r h a n d s t o g e t h e r a n d e x t e n d y o u r w r i s t s f u l l y .
"
Wrist
Normal range of movement\: 90º
https\://app.geekymedics.com/osce-guides/clinical-examination/hand-examination/ 5/1011/13/24, 7\:05 PM Guide | Hand examination
Instructions\: " P u t t h e b a c k s o f y o u r h a n d s t o g e t h e r a n d
"

Passive movement

Passive movement refers to a movement of the patient, controlled by the examiner. This involves the patient relaxing and
allowing you to move the joint freely to assess the full range of joint movement. It's important to feel for crepitus as you move
the joint (which can be associated with osteoarthritis) and observe any discomfort or restriction in the joint's range of
movement.
If abnormalities are noted on active movements (e.g. restricted range of movement), assess joint movements passively.
Ask the patient to fully relax and allow you to move their hand and wrist for them.
Warn them that should they experience any pain they should let you know immediately.
Repeat the above movements passively, feeling for any crepitus during the movement of the joint.
Active

Motor assessment

The following screening test will allow you to quickly assess the motor function of the radial, ulnar and median nerve.
Wrist and
Nerve assessed\: radial nerve
Muscles assessed\: extensors of the wrist and
Instructions\:
1. Ask the patient to hold their arms out in front of them with their palms facing downwards -
w i t h y o u r p a l m s f a c i n g t h e g r o u n d .
”
“ H o l d y o u r a r m s o u t i n f r o n t o f y o u ,
2. Ask the patient to extend their
“ E x t e n d y o u r
”
Index
Nerve assessed\: ulnar nerve
Muscles assessed\:
Instructions\:
https\://app.geekymedics.com/osce-guides/clinical-examination/hand-examination/ 6/1011/13/24, 7\:05 PM Guide | Hand examination
1. Ask the patient to splay their
l e t m e p u s h t h e m t o g e t h e r .
”
“ S p l a y y o u r
2. Apply resistance to the patient's index
Thumb ABduction against resistance
Nerve assessed\: median nerve
Muscle assessed\: abductor pollicis brevis
Instructions\: Ask the patient to turn their hand over so their palm is facing upwards and to position their thumb over the midline
of the palm. Advise them to keep it in this position whilst you apply downward resistance with your own thumb -
“ P o i n t y o u r
t h u m b s t o t h e c e i l i n g a n d d o n’ t l e t m e p u s h t h e m d o w n .
”
Finger extension against resistance (radial nerve)

Function

Assess the patient's hand function using the
Power grip
Instructions\: " S q u e e z e m y
"
Pincer grip
Instructions\: " S q u e e z e m y
"
Pick up a small object
Instructions\: " C o u l d y o u p l e a s e p i c k u p t h e c o i n o
"
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Power grip

Special tests

Tinel's test

Tinel's test is used to identify median nerve compression and can be useful in the diagnosis of carpal tunnel syndrome.
To perform the test, simply tap over the carpal tunnel with your
Interpretation
If the patient develops tingling in the thumb and radial two and a half
Tinel's test
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Phalen's test

the diagnosis.
If the history or examination
Ask the patient to hold their wrist in maximum forced
seconds.
Interpretation
If the patient's symptoms of carpal tunnel syndrome are reproduced then the test is positive (e.g burning, tingling or numb
sensation in the thumb, index, middle and ring
Phalen's test
Carpal tunnel syndrome
Carpal tunnel syndrome occurs as a result of compression of the median nerve as it traverses through the wrist via the
carpal tunnel. Typical clinical features include pain and paraesthesia in the distribution of the median nerve (index
thumb and lateral half of the ring
which receive motor innervation from the median nerve.

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
Example summary
" T o d a y I e x a m i n e d M r s S m i t h , a 3 2- y e a r-o l d f e m a l e. O n g e n e r a l i n s p e c t i o n , t h e p a t i e n t a p p e a r e d c o m f o r t a b l e a t r e s t ,
w i t h n o s t i g m a t a o f m u s c u l o s k e l e t a l d i s e a s e . T h e r e w e r e n o o b j e c t s o r m e d i c a l e q u i p m e n t a r o u n d t h e b e d o f r e l e v a n c e .
https\://app.geekymedics.com/osce-guides/clinical-examination/hand-examination/ 9/1011/13/24, 7\:05 PM Guide | Hand examination
" A s s e s s m e n t o f t h e h a n d s a n d w r i s t s r e v e a l e d a n o r m a l a p p e a r a n c e w i t h n o t e n d e r n e s s o n p a l p a t i o n . T h e r a n g e o f
m o v e m e n t o f t h e j o i n t s i n b o t h h a n d s w a s n o r m a l . T h e r e w a s n o e v i d e n c e o f w e a k n e s s o r s e n s o r y d i s t u r b a n c e i n t h e
h a n d s .
"
" I n s u m m a r y , t h e s e
"
" F o r c o m p l e t e n e s s , I w o u l d l i k e t o p e r f o r m t h e f o l l o w i n g f u r t h e r a s s e s s m e n t s a n d i n v e s t i g a t i o n s.
"

Further assessments and investigations

Neurovascular examination of the upper limbs.
Examination of the elbow joint and shoulder joint.
Further imaging if indicated (e.g. X-ray and MRI).

Reviewer

Mr Tejas Yarashi
Consultant Trauma & Orthopaedic Surgeon

References

1. James Heilman, MD. Adapted by Geeky Medics. Rheumatoid arthritis chronic changes. Licence\: CC BY-SA. Available from\:
[LINK].
2. David Jones. Adapted by Geeky Medics. Rheumatoid arthritis. Licence\: CC BY 2.0. Available from\: [LINK].
3. Davplast. Adapted by Geeky Medics. Bouchard’s nodes. Licence\: CC BY-SA. Available from\: [LINK].
4. Drahreg01. Adapted by Geeky Medics. Heberden’s nodes. Licence\: CC BY-SA. Available from\: [LINK].
5. Phoenix119. Adapted by Geeky Medics. Swan neck deformity. Licence\: CC BY-SA. Available from\: [LINK].
6 Alborz Fallah Adapted by Geeky Medics Boutonnière deformity Licence\: CC BY SA Available from\: [LINK]
Source\: geekymedics.com
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