Examination Of The Upper Limb The hand and wrist

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Examination of the hand consists of inspection, palpation and assessment of function. Since a full examination of function is lengthy, it is necessary to tailor the examination to the clinical history and the nature of the problem. For example, in a patient with lacerations of the digits, a thorough assessment of (he integrity of the tendons, nerves and circulation is essential. In contrast, in a patient presenting with stiffness, pain and swelling of Ihe hands the examination will he directed towards establishing the pattern of joint and tendon involvement (Table 8.2) and testing the principal hand functions, such as power grip and line pinch.

Examination sequence

□ Inspect the hands and wrists carefully (Table 8.10). Look specifically for skin and nail changes, muscle wasting, joint deformity and swelling of joints, tendon sheaths or surrounding tissue.

□ Palpate the joints of the hands and wrists and periarticular soft tissues to elicit tenderness and to identify the bony or soft tissue nature of any swelling.

□ Palpate the flexor tendon sheath, by placing the examining index finger across the volar aspect of the patient's fully extended fingers and then asking the patienl (o open and close the fingers, allowing crepitus to be detected.

□ Palpate the flexor tendons from the sides to delect synovial swelling ((he Savill pinch test).

□ Palpate for local swellings of tendons, especially at (he mouth of the fibrous flexor sheath. If a swelling on the tendon is felt, look for triggering of the finger (i.e. locking of the finger in flexion as (he tendon nodule engages in the mouth of the fibrous sheath).

□ Ask the patient to perform fine pinch (as if threading a needle).

□ Note the grip strength by asking the patient to grasp two of the examiner's fingers. If the range of movements of the joints is not full, the patient may be unable to grip two or even three of the examiner's fingers.

□ Note the range of wrist dorsiflexion (0-90 degrees),

□ Note the range of wrist flexion (0-90 degrees).

Specific muscles and tendons

Undertake detailed testing of the individual muscles and tendons only if indicated.

□ Flexor digitorum profundus (FDP) (flexes the distal interphalangeal joints). Ask the patient to flex the DIP joint (0-90 degrees) while holding the finger in exiension ai (he PIPjoini (Fig. 8.15A).

□ Flexor digitorum sublimis (FDS) (flexes the PIP joints). It is necessary to eliminate the action of FDP which acts en masse. While holding the other fingers in full extension to block the action of FDP, ask the patient to flex the PIP joint in question (Fig. 8.I5B).

□ Thenar muscle supplied by median nerve (abduction 0-80 degrees). To test the action of abductor pollicis brcvis, ask the patient to abduct the thumb vertically from the palm and to hold it against resistance. Test opposition by asking Ihe patient to touch the terminal

TABLE 8.10 Examples of visible abnormalities of the hands associated with rheu mafic disease

Abnormality

Appearance and consistency

Typical site

Associated rheumatic disease

Heberden's nodes Bouchard's nodes Rheumatoid nodules Tophi

Calcific deposits Dilated capillaries

Small bony nodules Small bony nodules Fleshy and firm White subcutaneous White subcutaneous (Use magnifying glass)

Dorsum of DIP joints

Dorsum of PIP joints

Extensor surface of knuckles

Juxta-articular

Finger pulp

SCL, DM

SCL, DM, SLE

OA, osteoarthritis: RA, rheumatoid arthritis; SCL, scleroderma; DM, dermatomyositis; SLE systemic lupus erythematosus

Dorsum Hand With Rheumatoid Arthritis
Fig. 8.15 El Flexor digitorum profundus. EB Flexor digitorum sublimis.
Scleroderma Knuckles

Fig. 8.16 E] Adduction and BO opposition of the thumb.

Opposition involves rotation. It is commonly tested by asking the patient to touch the tip of the smalt linger with the thumb.

phalanx of the little finger with the thumb and to maintain this position against resistance (Fig. X.16B).

□ Thenar muscle supplied by ihe ulnar nerve (adduction of the thumb). Ask the patient to hold a card between the palm and the adducled thumb. If the adductor is weak, the thumb cannot be held straight and flexes at the MCP and IP joints (Froment's sign ) (Fig. 8.17A).

□ Extensorpollicis longus principally elevates the thumb (hitch-hiker's thumb). Ask the patient to place the palm on a flat surface and to lift the thumb like a hitch-hiker

(Fig. 8.17R). The patient will only be able to do so if this tendon is intact.

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