Common abnormalities

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Movements. Some people, including those of Mediterranean origin, 'speak' with Iheir hands. For example, the hand pressed flat on the top of the head accompanying a complaint of hcadache suggests a psychogenic symptom 'something weighing on the mind'.

Tremors are studied with the hands at rest and then outstretched. Characteristic tremors are described in Table 2.4 (p. 28).

Tetany may be recognised by the presence of carpal spasm, where the hand(s) adopt a characteristic position with flexion of the metacarpophalangeal joints, extension of the interphalangeal joints of Ihe lingers and thumb with opposition of the thumb, so-called main d'accoucheur. Latent tetany may be detected by Trousseau's sign (see Fig. 2.26). This is positive where carpal spasm occurs within 4 minutes of inflation of a sphygmomanometer cuff on the upper arm to a level above the systolic blood pressure.

Posture. This may be almost diagnostic. Examples include the flexed hand and arm of hemiplegia, wrist drop or radial nerve palsy and ulnar deviation in long-standing rheumatoid arthritis.

Shape. Trauma is ihe commonest cause of deformity of the hand. Some diagnostic shapes include the long thin lingers of araehnodactyly, while a short fourth metacarpal, best seen when making a fist, strongly suggests a diagnosis of Turner's syndrome in a girl with primary amenorrhoea. Short metacarpals, especially the fourth and fifth, are found in. patients with pseudohypoparathyroidism.

Size. In acromegaly the hands are large and broad. Rings may be difficult to remove or may have been cut off or enlarged, The increase in bulk consists largely of .soft tissues.

Trousseau Syndrome
Fig, 2.26 Trousseau's sign.
Lupus Vasculitis Finger

Fig. 2.27 The fingers as a diagnostic aid. B Cyanosis and finger clubbing in a patient with congenital heart disease. @] Acute vasculitic lesions in a boy with systemic lupus erythematosus.

These are also thickened in myxoedema. Oedema may he part of a generalised process or may arise from local venous or lymphatic obstruction or disuse, as with a hemiplegia.

Colour. By and large changes in the colour of the hands are similar to those of the skin in general (p. 26). The purported cigarette consumption should be reconciled with a degree of nicotine staining of the fingers. Coal miners may have small blue tattoo marks in the skin of their hands and in other sites where particles of coal dust have been embedded in the scars of minor injuries. In miners and in those with professional tattoos, the blue colour in the skin is due to black particles (carbon or Indian ink) changed in appearance by the scatter of light as it passes through and is reflected back from the skin. This explains why veins normally look blue, while in the elderly, with very thin skin, the true red colour of the blood may be seen.

Temperature. In a cold or cool climate the temperature of the patient's hand is a good guide to the blood flow. If the hand is warm and cyanosed, it can be deduced that arterial oxygen saturation is reduced.

The combination of central cyanosis and linger clubbing suggests congenital cyanotic heart disease (Fig. 2.27A). In most patients with heart failure the hands tend to be cold and cyanosed due to vasoconstriction in response to a low cardiac output. If they are warm the cause of the heart failure may be hyperthyroidism or cor pulmonale.

Skin

The smooth, hairless hands of a child become lined and hairy in the adult male unless hypogonadism is present, Manual work may produce specific callosities due to pressure at characteristic sites. In contrast, disuse results in a soft, smooth palmar skin and prolonged recumbency affects the soles likewise.

The skin may feature in a wide variety of specific skin disorders such as contact dermatitis (see Fig. 2.I9D, p. 42), Skin changes may also occur as the dermatological manifestation of systemic disease (Fig. 2.27B). Likewise v itiligo may be restricted to Ihe hands or face or widespread (Fig. 2,28). I(s presence may indicate underlying autoimmune disease.

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