Clinical Examination

Hand Examination

Introduction:

Wash your hands.

Introduce yourself to the patient including your name and role.
Confirm the patient’s name and age.
Briefly explain what the examination will involve using patient-
friendly language: “Today I’m going to examine the bones of your hands and
wrists. The examination will involve me first looking at the hands, then feeling
the joints and finally asking you to do some movements.”
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.
General inspection
Perform a brief general inspection of the patient, looking for signs suggestive of underlying
pathology:
 Scars
 Wasting of muscles.

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
 Scars
 Swelling.
 Skin colour
 Bouchard’s nodes.
 Heberden’s nodes.
 Swan neck deformity: .
 Z-thumb: .
 Boutonnières deformity
 Skin thinning or bruising
 Psoriatic plaques
 Muscle wasting:
 Splinter haemorrhages
 Nail pitting and onycholysis
  Palmar aspect of the hand
With the patient’s palms facing up, inspect each hand for signs suggestive of underlying
pathology:
 Hand posture
 Scars:
 Swelling:
 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 fingers and thumb.
 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.
 Janeway lesions
 Osler’s nodes
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 inflammatory arthritis.
Radial and ulnar pulse
Palpate the radial and ulnar pulse to confirm adequate blood supply to the hand.
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).
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 finger.
2. Assess ulnar nerve sensation over the hypothenar eminence and little finger.
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Assess and compare joint temperature

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Assess the radial pulse

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Assess the ulnar pulse

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Palpate the thenar and hypothenar eminences

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Assess palmar thickening

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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.

Tenderness:
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 inflammatory
arthropathy.
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 snuffbox
Palpate the anatomical snuffbox for tenderness which is suggestive of
a scaphoid fracture.
Bimanual wrist palpation
Palpate the wrists for evidence of joint line irregularities or tenderness.
Elbows
Elbow palpation
Palpate the patient’s arm along the ulnar border to the elbow and note
any tenderness, rheumatoid nodules or psoriatic plaques.

Assess median nerve sensation

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Assess ulnar nerve sensation

Palms down (dorsum)
Radial nerve sensation
Assess radial nerve sensation over the first dorsal webspace.
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 first for comparison.
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: “Open your fist and splay your fingers.”
Finger flexion
Instructions: “Make a fist.”
Wrist extension
Normal range of movement: 90º
Instructions: “Put the palms of your hands together and extend your wrists fully.”
Wrist flexion
Normal range of movement: 90º
Instructions: “Put the backs of your hands together and flex your wrists fully.”
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 finger flexion

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Active wrist extension

Active wrist flexion

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Passive wrist flexion and extension
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Motor assessment
The following screening test will allow you to quickly assess the motor function of
the radial, ulnar and median nerve.
Wrist and finger extension against resistance
Nerve assessed: radial nerve
Muscles assessed: extensors of the wrist and fingers
Instructions:
1. Ask the patient to hold their arms out in front of them with their palms facing downwards
–“Hold your arms out in front of you, with your palms facing the ground.”
2. Ask the patient to extend their fingers and wrist joints, keeping their hands in this position
whilst you apply resistance – “Extend your fingers out in front of you, cock your wrists back
and don’t let me pull them downwards.”
Index finger ABduction against resistance
Nerve assessed: ulnar nerve
Muscles assessed: first dorsal interosseous (FDI)
Instructions:
1. Ask the patient to splay their fingers and stop you from pushing their fingers together
– “Splay your fingers outwards and don’t let me push them together.”
2. Apply resistance to the patient’s index finger using your own index finger to assess
abduction.
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 – “Point your thumbs to the
ceiling and don’t let me push them down.”
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Finger extension against resistance (radial nerve)

Finger ABduction against resistance (ulnar nerve)

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Thumb ABduction against resistance (median nerve)
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Function
Assess the patient’s hand function using the fine motor screening tests below.
Power grip
Instructions: “Squeeze my fingers with your hands.”
Pincer grip
Instructions: “Squeeze my finger between your thumb and index finger.”
Pick up a small object
Instructions: “Could you please pick up the coin off the table.”

Power grip
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Figure 28. Pincer grip

Assessment of hand dexterity

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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 finger.
Interpretation
If the patient develops tingling in the thumb and radial two and a half fingers this is
suggestive of median nerve compression.

Tinel's test
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Phalen’s test
If the history or examination findings are suggestive
of carpal tunnel syndrome, Phalen’s test may be used to further support the diagnosis.
Ask the patient to hold their wrist in maximum forced flexion (pushing the dorsal surfaces of
both hands together) for 60 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 fingers).
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Phalen's test
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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 finger, thumb
and lateral half of the ring finger). Grip weakness can also develop secondary to wasting of
the thenar muscles which receive motor innervation from the median nerve.

To complete the examination…

Explain to the patient that the examination is now finished.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your findings.
Example summary
“Today I examined Mrs Smith, a 32-year-old female. On general inspection, the patient
appeared comfortable at rest, with no stigmata of musculoskeletal disease. There were no
objects or medical equipment around the bed of relevance.
“Assessment of the hands and wrists revealed a normal appearance with no tenderness
on palpation. The range of movement of the joints in both hands was normal. There was
no evidence of weakness or sensory disturbance in the hands. “
“In summary, these findings are consistent with a normal hand and wrist examination.”
“For completeness, I would like to perform the
following further assessments and investigations.”
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).