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Approach to the Hand Examination

Approach to the Hand Examination. Karen Booth. Topics for Discussion. Review of Anatomy History Physical Examination Cases. Anatomy. Bones/Joints Muscles Nerves Tendons Vascular. History. Mechanism of injury Timing, Pain Motor/sensory deficits Constitutional symptoms

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Approach to the Hand Examination

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  1. Approach to the Hand Examination Karen Booth

  2. Topics for Discussion • Review of Anatomy • History • Physical Examination • Cases

  3. Anatomy • Bones/Joints • Muscles • Nerves • Tendons • Vascular

  4. History • Mechanism of injury • Timing, Pain • Motor/sensory deficits • Constitutional symptoms • Hand Dominance • Occupation, hobbies, ADLs • PMHx: • Tetanus status, Allergies • Systemic disease (DM, CTD)

  5. Physical Examination*compare both sides* • 1. Bones/Joints: • LOOK/Inspection • SEADS • FEEL/Palpation • MOVE/ Range of Motion • Active • Passive

  6. Physical Examination*compare both sides* • 2. Vascular: • Colour, temperature • Pulses • Capillary Refill

  7. Physical Examination*compare both sides* • 3. Nerves: Sensory • Median: pulp of index finger • Ulnar: pulp of 5th digit • Radial: 1st dorsal webspace • Digital Nerves: 2 point discrimination

  8. Physical Examination*compare both sides* • 3. Nerves: Motor • Extrinsic • Median:DIP flexion of index finger (FDP) • Ulnar:DIP flexion of 5th finger (FDP) • Radial: Extension of wrist/thumb • (ECR/EPL)

  9. Physical Examination*compare both sides* • 3. Nerves: Motor • Intrinsic • Median: Thumb abduction (APB) • Ulnar: Interossei • -DAB • -PAD • Radial: none!

  10. Physical Examination*compare both sides* • 3. Tendons: • Flexor Digitorum Profundus (FDP): flex DIP • Flexor Digitorum Superficialis (FDS): flex PIP • Extensor Digitorum Communis (EDC): extension

  11. Physical Examination*compare both sides* • 3. Tendons:

  12. Case #1 • RFA: laceration to index finger • History: • MOI: kitchen knife, vegetables • Location: R side, palmar, distal to PIP jt • Occupation: office, Hobby: instrument • Handedness: R, dominant • PMHx: NKDA, tetanus: UTD • no systemic disease

  13. Case #1: laceration to index finger • Examination: Compare both sides • Bones/Joints: • Look/Feel/Move – joint above/below injury • No swelling, painful in area • Normal PIP flexion + extension • Difficulty with flexion of DIP • Vascular: • Good colour/temperature • Normal Pulses • Normal capillary refill

  14. Case #1: laceration to index finger • Examination: Compare both sides • Neuromuscular: • Sensory: N median, ulnar, radial, digital nerves • Motor: N intrinsic fxn • Tendons: • MCP jt: N flexion/extension • PIP: N flexion of PIP = FDS intact • DIP: absence of flexion of DIP

  15. Case #1: laceration to index finger • Diagnosis: • injury to FDP of index finger • Management: • Clean area, irrigate with NS, apply sterile dressing • Antibiotic Prophylaxis, tetanus if necessary • X-Ray – r/o fracture • Plastics: • operative primary repair of tendon within 14 days

  16. Case #2 • RFA: painful swollen joints in hands • History: • Physical: • Bones/Joints: • Inspection: SEADS • Feel: • Move:

  17. Case #2 Common arthritic findings in the hand

  18. Case #2 Common arthritic findings in the hand • RA: • subluxation of MCP • radial deviation of wrist • ulnar deviation of the fingers

  19. Common Deformities in the Hand • Boutonniere: • hyperextended DIP and flexed PIP • central slip of extensor tendon insertion into middle phalanx

  20. Common Deformities in the Hand • Swan Neck: • flexed DIP and hyperextended PIP • PIP volar plate injury

  21. Common Deformities in the Hand • Mallet Finger: • DIP in flexion with loss of extension • due to damage to extensor tendon

  22. Case #3 Common Problems in the Hand • Trigger finger/stenosing tenosynovitis • inflammation of synovium causing friction between flexor tendon and pully sheath • locking of finger with flex/ext • palpable nodule over MCP • painful

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