Hand examination

Click the button to download our free one page A4 Summary!

Introduction

  • Wash Your hands
  • Introduce yourself by name and role
  • Check the patient’s identity – name and Date of Birth
  • Explain the procedure – why you need to do it and what does it involve
  • Ask for consent
  • Expose the patient appropriately
  • Check if the patient is currently in any pain
How to Introduce Yourself

“Good morning, my name is .. and I am a medical student. Can I just check your name and date of birth?

-I have been asked to do an examination of your hands, which will involve me looking at, feeling and moving the joints in your hand. Is that okay?

Would you mind rolling up your sleeves for me please?

And can I just check whether you are in any pain?”

Bedside Inspection

  • Bedside examination paraphernalia of MSK conditions 
  • Observe the patient by standing at the end of the bed.
  • Comment on whether the patient is ABC:

A – Alert         B – (normal) Body habitus         C – Comfortable at rest

  • Observe the surroundings and comment about objects of note 

Describe the objects or items around a patient’s bedside that will give you an idea into the condition that they might have. It is important to highlight this to the examiner as this can give you many clues about the patient’s underlying diagnosis. Things to look for include

  • Medication – can you see any medication on the patient’s bedside e.g. pain relief?
  • Mobility aids – gives an idea about the functional status of the patient.

 

Observation

Action: Ask the patient to hold their hands out and inspect the patient’s hand from the dorsal side, palmar side, as well as the forearms and elbows.

DORSUM OF THE HAND:

Assess for:

–> Scars: These are indicative of previous hand surgery or trauma.

–> Inflammatory changes: These include swelling and erythema. This is seen in a host of inflammatory conditions such as rheumatoid arthritis, septic arthritis or any infective process. 

–> Nail changes: This includes pitting of the nails and onycholysis (nails coming off the nail bed). These are signs seen in psoriatic arthritis. 

–> Bony deformities: Certain conditions lead to specific joint deformities in the hand. 

a) Osteoarthritis– Bouchard nodes, Heberden’s nodes

b) Rheumatoid arthritis– Swan-neck deformity, Boutonnieres deformity, Z thumb, ulnar deviation. 

 

Boutonniere deformity

Associated with rheumatoid arthritis

Swan-Neck deformity

Associated with rheumatoid arthritis

Heberden Nodes

Associated with osteoarthritis

Onycholysis

Associated with psoriatic arthritis

Nail Pitting

Associated with psoriatic arthritics

PALMAR ASPECT:

Assess for:

 –> Skin: Scars (for signs of past surgical incisions), erythema, skin thinning, swelling. 

–> Thenar/hypothenar wasting: It is important to compare between the hands to see the muscle bulk of the thenar and hypothenar eminence. 

 

 ELBOW:

Assess for:

–> Psoriatic plaques: These are scaly, silver red lesions that can be present in psoriasis. This is an inflammatory condition where abnormal T cell activity gives rise to excessive keratinocyte proliferation. 

 

Plaque Psoriasis

Feel – Palms Facing Up

Action: Ask the patient to put their hands out with their palms pacing upwards. Using the back of your hands, feel down from their forearms over their hands to feel the temperature:

Assess for:

–> Temperature:  A raised temperature is indicative of an inflammatory process occurring. This could be due to an inflammatory arthritis e.g. rheumatoid arthritis, septic arthritis.

 

Action: Feel for the Radial Pulse and then the ulnar pulse on each wrist in turn. 

Assess for:

–> Rate (bpm),  rhythm (regular, regularly irregular, irregularly irregular) and character (thready, bounding): 

What the Radial Pulse Tells You

The radial pulse gives you a lot of information about the state of the cardiovascular system. There are 3 main variables to talk about when measuring the radial pulse:

1. Rate:

– A rate of <60bpm is considered bradycardia

– A rate of >100bpm is considered tachycardia

2. Rhythm: There are 3 main rythms to talk about:

– Regular – this will most likely be due to sinus rhythm, however you can get this in ventricular tachycardia

– Regularly irregular – this will most likely be due to a form of heart block

– Irregularly irregular – this is one not to miss and is most likely due to atrial fibrillation.

3. Character – this is gives you an indication of the strength of the impulse. It can be:

– Thready – can be seen if the BP is low such as in shock if the patient is peripherally shutting down

– Bounding – seen in CO2 retention. 

Action: Palpate the palmar aspect of the patients hands in turn assessing for the following features. 

a. Slide your thumb over the palm to assess.

b. Using bimanual palpation, feel for the muscle bulk over the thenar and hypothenar eminences.

Assess for:

–> Dupuytren’s contracture: This is an abnormal thickening of the skin in the palm of your hand at the base of your fingers.  In Dupuytren’s disease, the fascia overlying the tendon becomes thicker and forms cords and bumps. It is associated with excessive alcohol use, increasing age, male gender and diabetes.

–> Thenar eminence wasting: The muscles in the thenar eminence include opponens pollicis, abductor pollicis brevis and flexor pollicis brevis. These are supplied by the recurrent branch of the median nerve. The median nerve goes under the flexor retinaculum, and so in carpal tunnel syndrome, this leads to wasting of the muscles in the thenar eminence. 

–> Hypothenar eminence wasting: These muscles include abductor digiti minimi muscle, the flexor digiti minimi brevis muscle, the opponens digiti minimi muscle, and the palmaris brevis muscle. These are supplied by the ulnar nerve. Therefore, damage to the ulnar nerve or to the nerve roots T1 lead to wasting of the hypothenar eminence. 

 

Carpal Tunnel Syndrome

Gives wasting of the thenar eminance

Dupuytrens Contracture

Feel – Palms Facing Down

Action: Ask the patient to turn their hands over so their palms are now facing downwards.  their hands out with their palms pacing upwards. Using the back of your hands, feel down from their forearms over their hands to feel the temperature:

Assess for:

–> Temperature:  A raised temperature is indicative of an inflammatory process occurring. This could be due to an inflammatory arthritis e.g. rheumatoid arthritis, septic arthritis.

 

Action: Gently squeeze across the metacarpophalangeal (MCP) joints and observe for verbal and non-verbal signs of discomfort.

Assess for:

–> Pain/discomfort: This is indicative of an inflammatory process in these joints. This is associated with an inflammatory arthritis such as rheumatoid. Remember, this affects both the hands and feet.

 

Action: Using a bimanual technique, palpate each of the joints of the hand. Start proximally and then work distally. 

a. Carpometacarpal joint of the thumb (CMCJ)

b. Metacarpophalangeal joint (MCPJ)

c. Proximal interphalangeal joint (PIPJ)

d. Distal interphalangeal joint (DIPJ)

Assess for:

–> Swelling and tenderness: The pattern of joints affected can give you a big indication of the type of joint pathology (if present) the patient is suffering from. 

i) Rheumatoid arthritis – commonly affects the PIP and MCP joints, and gives a symmetrical pattern in both hands. There is usually sparing of the DIP and the CMCJ  joints.

ii) Osteoarthritis – This gives an asymmetrical pattern of disease and will usually affect the DIP joints as well as the CMCJ joint.

iii) Psoriatic arthritis – This usually affects the DIP joints of the hand. In addition, you may find nail changes, skin plaques. It also can lead to specific deformities like telescoping and pencil-in-cup deformity. 

Rheumatoid Arthritis

Affects MCP and PIP. Gives ulnar deviation of fingers, Z-thumb and joint deformities

Osteoarthritis

Affects DIP joints. Associated with Heberden and Bouchard node formation

Action: Palpate the anatomical snuffbox 

Assess for:

–> Tenderness: This could be a sign of a scaphoid fracture. This is very serious due to the blood supply of the scaphoid bone. If left untreated, this can lead to avascular necrosis of the scaphoid bone. 

Anatomical Snuffbox

Action: Palpate the forearms, working your way up to the elbows on both sides. 

Assess for:

–> Nodules or psoriatic plaques: These are signs of psoriasis. They will feel nodular or like roughened skin. It may be harder to see psoriatic plaques in people of different skin colour/hairyness, which is why palpation is also very important. 

Plaque Psoriasis

Feel – Sensation

Testing for sensation is essential as it can help distinguish whether the condition is affecting the nervous innervation of the hand. With sensation, you want to characterise the distribution of sensory changes and compare side to side. 

Action: Test the sense of light touch using a piece of cotton wool (or lightly tapping)

a. Ask the patient to close their eyes and brush the cotton wool on their sternum. Explain that this is what it will feel like

b. Tell the patient that you will tap them lightly. Ask them to say “Yes” when they can feel something.

c. Brush the cotton wool in the following areas, which are supplied by particular nerves. For each dermatome, compare side by side, and ask “Does it feel the same on both sides?”

Median nerve Thenar eminence + Tip of Index finger
Ulnar nerve Hypothenar eminence + Tip of little finger
Radial nerve First dorsal webspace

 

Nerve Supply Upper Limb

Move 

In the MSK examinations, we assess both active (patient doing the movement unaided) and passive movement (where the examiner does the movement for them). This is because different pathologies will produce pain on active or passive movement, or sometimes both. This is crucial in helping the clinician to diagnose the condition. 

–> Pain on active movement – Tendon issues, muscle conditions

–> Pain on passive and active movement – Joint conditions, fractures

ACTIVE MOVEMENT:

Action: To test the movements, ask the patient to do the following movements giving very clear instructions. Test each hand in turn.

a. Finger Flexion – Ask the patient to make a fist.

b. Finger extension –  Ask the patient to open their fist and to splay their fingers.

c. Wrist Flexion – Ask the patient to put the backs of their hands together so that their fingers are facing downwards. 

d. Wrist extension  – Ask the patient to put the palms of their hands together so that their fingers are facing upwards. This will look like the patient is praying.

PASSIVE MOVEMENT:

This time, ask the patient to relax and allow you to move their hands freely. 

Actions: Repeat all the movements but this time doing it passively.  Test each hand in turn. 

Assess for:

–> Crepitus: This is a sensation or noise when you move a joint which can be described as clicking, cracking, creaking, crunching, grating or popping. The sound is heard when two rough surfaces come into contact—for example, in osteoarthritis or rheumatoid arthritis when the cartilage around joints erodes and the surfaces in the joint grind against one another. Therefore, could be a sign of arthritis in the hip joint. 

–> Range of Motion: For each movement, assess whether the patient has a normal range of motion. When assessing this, try and distinguish whether this the ROM is limited due to a structural abnormality or pain. 

 

Finger Flexion

Finger Extension

Wrist Flexion

Wrist Extension

Move – Neuro

In the hand examination, it is important to do a screening test of the motor function of the 3 nerves which give motor innervation to the hand, the median, radial and ulnar nerve.  This is done by testing specific movements under resistance to assess the power in specific muscles, which are supplied by these nerves. 

Median Nerve:

Action: Ask the patient to turn their hands over so that their palms are facing upwards, and point their thumbs up.  

Assess for:

–> Thumb Abduction:  Apply downward pressure on the thumb and ask the patient to resist you. 

– Test aduction pollicis brevis

– Nerve root = T1 (median nerve)

Ulnar Nerve:

Action: Ask the patient to put their hands out so that their palms are facing downwards and then to splay their fingers. 

Assess for:

–> Finger abduction: With your fingers, apply pressure to try and push in the little finger whilst asking the patient to resist you. Then try to push in the index finger

– Tests abductor digiti minimi and interossei

– Nerve root = T1 (ulnar nerve)

Radial Nerve:

Action: Ask the patient to cock back their wrists so their fingers are facing upwards. 

-> Wrist Extension: Ask the patient to keep their wrists extended whilst you try to push their wrists down. Tell the patient, “Don’t let me push your wrists down.”

–> Finger extension: You can also ask the patient to keep their fingers extended whilst you try to push their fingers down. 

– Tests Extensor carpi groups

– Nerve roots = C7 (radial nerve)

Move – Function

In the hand examination, it is important to do a screening test to assess the general function of the hands. This is because the hands are incredibly important and allow us manual dexterity, which is essential in living a normal life. To assess this, ask the patient to do some simple movements.

Screening:

Action: Ask the patient to undo the top button of their shirt. Alternatively if they are not wearing a shirt with buttons, you can ask them to pick up a coin with one hand on the table. 

Assess for:

–> Dexterity: This is a good screening test of the patient’s general motor dexterity. 

Pick up coin

Pincer Grip:

Action: Ask the patient to squeeze your finger in between their thumb and index finger. 

Assess for:

–> Pincer Grip: This is an important skill which allows functions like picking up a pen and writing.

Pincer Grip

Power Grip:

Action: Place 2 fingers in your hands patient’s hands and ask them to squeeze your fingers as hard as they can.

Assess for:

–> Power grip: The grip strength can be reduced by many factors e.g. pain (due to inflammatory), swelling (physical restriction) or muscle wasting (damage to nerves) 

Power Grip

Special tests

In the hand examination, there are 2 special tests that you may be expected to do in your OSCE. These are used to assess for carpal tunnel syndrome. 

Carpal tunnel syndrome is a condition which is caused due to compression of the median nerve in the wrist as it passes under the carpal tunnel. This compression leads to symptoms of median nerve dysfunction – this is primarily seen in the thenar eminence:

Symptoms:

– Wasting of thenar muscles

– Paraesthesia (tingling) over the medial aspect of the palm due to sensory dysfunction

– Weakness in thumb abduction, opposition –> seen as weakness in precision + power grip.

The 2 tests you need to learn about are Tinel’s Test and Phalen’s Test:

Tinel’s Test:

Action: Ask the patient to place their hand on your lap or on the table with their palms facing upwards.

a. Ask the patient to relax their hand so it in a natural position

b. Tap over the carpal tunnel 

c. Ask the patient if they can feel any abnormal sensation developing in their hand.

Assess for:

–> Tingling: The median nerve gives innervation to the palmar aspect of the first 3 and 1/2 digits of the hand. If tingling is reproduced over this area, this is a sign of median nerve compression. This is suggestive of carpal tunnel syndrome.

 

Tinels' Test

Phalen’s Test:

Action: Ask the patient to put the backs of their hands together so that their fingers are facing downwards. (similar to what you did earlier in the examination). Ask the patient to hold their wrists in this position for 1 minute. 

Assess for:

–> Pain/tingling: Holding the wrists in forced flexion tenses the carpal tunnel. If there is carpal tunnel syndrome this will cause compression of the nerve reproducing the symptoms of carpal tunnel syndrome. 

Phalen's Test

On Completion

You must remember that the physical examination is only one part of the overall assessment of your patient. Therefore, when completing your exam, state that you would do the following in order to complete your assessment of the patient. Much of this will depend on whether you have discovered any particular findings or have an idea about the overall diagnosis. However, some essential things to talk about are:

“To complete the examination, I would do a number of steps…”

Bedside: 

  • (History) Take a full history
  • (Observations) Examine neurovascular state of the hands e.g. pulse, sensation, proprioception
  • (Corresponding examination)  Examine joint above (elbow)

Bloods – FBC, inflammatory markers including CRP, rheumatoid factor etc. 

Imaging – X-ray of the hands

How to Present Your Findings

“I conducted a hip examination on … who seemed well and comfortable at rest.

  • On inspection there were no peripheral signs or paraphernalia of MSK disease
  • There were no visible signs of MSK on inspection
  • There were no palpable masses and the joints were no tender
  • No tenderness in the anatomical snuffbox
  • There was full range of movement on passive and active flexion and extension
  • Sensation was normal in the hands 

In summary, this was a normal hand examination.”

Sources

Boutonniere Deformity – Alborz Fallah, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

Swan-Neck Deformity – User:Phoenix119, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

Heberden’s Nodes – Drahreg01, CC BY-SA 3.0 <http://creativecommons.org/licenses/by-sa/3.0/>, via Wikimedia Commons

Onycholysis – CopperKettle, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

Nail pitting – Seenms, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

Psoriatic Plaques – MediaJet, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

Carpal Tunnel Syndrome – Dr. Harry Gouvas, MD, PhD, Public domain, via Wikimedia Commons

Dupuytren’s contracture – Frank C. Müller, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons

Rheumatoid Hands – Laboratoires Servier, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

Osteoarthritis Hands – Laboratoires Servier, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

Anatomical Snuffbox – Linke_Hand.jpg: Drahreg01derivative work: Yosi I, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

Nerve Supply Upper Limb – Henry Vandyke Carter, Public domain, via Wikimedia Commons

Finger Flexion – Mizunoryu, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

Finger extension – wimayr, CC BY 2.0 <https://creativecommons.org/licenses/by/2.0>, via Wikimedia Commons

Wrist Flexion – LittleT889, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons

Wrist Extension –  https://pixabay.com/vectors/hands-praying-christian-pray-304398/. Pixabay License – No Attribution Required. 

Pick Up coinPublic Domain Vectors

Pincer Grip – User:Speedy sharma, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

Power Griphttps://www.flickr.com/photos/dorsner/3933768735. Attribution – NonCommercial-ShareAlike 2.0 Generic (CC BY-NC-SA 2.0)

Tinel’s Test – https://freedpt.wordpress.com/2016/10/17/tinels-sign-test-at-the-wrist-for-the-median-nerve/

Phalen’s Test – LittleT889, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons

Sign up to In2Med to get Access to our A4 OSCE summaries

Want a A4 summary template for that last minute revision before your OSCEs. Sign up to In2Med to gain access to our downloadable A4 OSCE summaries.

Feel free to download these, print them off, annotate them and make them your own. Just click on the button below to join the In2Med community and get access to these resouces!

Disclaimer

The intended purpose of this website is to be used as a resource for revision for exams. It should not be used as a guideline or reference for clinical practice/decision making or by patients looking for medical information or advice. In2Med takes no responsibility for any loss or damaged resulting from the use of information from this website.

Sign up to our mailing list to get an exclusive 10% discount on In2Med courses!