a. Inspect and palpate wrists; metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints of fingers; and carpometacarpal (CMC), MCP, and interphalangeal (IP) joints of thumbs (Fig 1-4). Note shape and deformities: boutonniere, swan neck, and ulnar deviation.
FIG. 1-4. Finger and thumb joints. MCP, metacarpophalangeal; PIP, proximal interphalangeal; DIP, distal interphalangeal; CMC, carpometacarpal; IP, interphalangeal.
b. Soft-tissue swelling has a spongy consistency and should be sought on the dorsum of the wrist distal to the ulna and over the radiocarpal joint. On the volar surface, the normal step-down from hand to forearm may be obliterated by soft-tissue swelling. Volar synovitis may be associated with carpal tunnel syndrome. Tapping on the volar aspect of the wrist may elicit paresthesias radiating into the radial three fingers, or even the forearm. This positive Tinel's sign is consistent with carpal tunnel syndrome. Thenar atrophy would further support this diagnosis.
c. All finger joints should be examined by inspection and palpation for soft-tissue swelling, capsular thickening, and bony enlargement.
Table 1-1. Average joint motion e. The fist is described as 100% when all fingers reach the palm of the hand and the thumb closes over the fingers. Halfway fist closing is recorded as 50%; less than 50% and 75% are other possible intermediate measurements. The distance from fingertips to palm can also be recorded.
f. Grip is quantified by noting the patient's maximum strength in grasping two fingers of the examiner. Pinch is assessed by the force necessary to break the patient's pinch between index finger and thumb.
g. Pronation and supination are combined functions of the elbow and wrist and are determined by having the patient hold the forearm horizontal and the thumb up. Pronation and supination are measured in degrees from the neutral position with the hand turning palm up and palm down ( Fig 1-5).
FIG. 1-5. Forearm pronation and supination.
F. While the patient is sitting, customary physical examination of the neck and chest should be performed; it should include examination of sternoclavicular joints and measurement of chest expansion, which should be greater than 5 cm in the nipple line.
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