hand examination in primary care
TRANSCRIPT
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Hand examination in primary care
Ian GrantConsultant Plastic Surgeon
Addenbrooke’s Hospital Cambridge
2010
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ExaminationBegins when the patient enters the room
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Examination: sequence
LookFeelMoveProvokeQuantify
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Look
Surface anatomy Posture: cascade Deformity, swelling, skin quality
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Ulnar nerve palsy – first web wasting, small and ring finger MCP hyperextension, PIP joint flexion
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Thenar wasting
Carpal tunnel syndrome
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Posture: Boutonnière deformity – central slip avulsion - division
IGIGIG
IG IG IG
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Posture: extended digitFDP avulsion ring finger - rugby shorts
IGIGIG
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Posture: extended digitFDP rupture - bricklayer
IGIGIG
IG
IG
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Deformity:Dupuytren’s disease(cords, pits, nodules)
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Rheumatoid arthritis - posture / deformity
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Thumb OA – posture, CMC subluxation
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Palpate
Skin quality and temperature
Tenderness: radial to ulnar, proximal to distal, dorsal then volar
Leave likely tender areas to last
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Move: active then passive
Wrist Flex70
Radial 15
Pronation85
Extend50
Ulnar 30
Supination85
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Move
Fingers
Joint MotionMCPJ 0-90º
PIPJ 0-110ºPIPJ 0-70ºTotal 270º
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Neurological examination
Sensibility Sensation: static 2 point discrimination Ten test – compare 2 sides 10/10 –
light moving touch
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Grip and strength
Muscle grade MRC 0-5 0= no contraction 1= Trace of contraction 2= Muscle contraction but not against gravity 3= Move limb against gravity 4= good but not normal 5= Normal
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Grips
Power (all 4 fingers) Pinch (tip to tip) Key (thumb pulp) Tripod (three fingers) Karapandji - opposition
testing (the patient touched the tip of the thumb to the index, middle, ring and small finger tips -
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Vascular
Capillary refill Allen’s test
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Bone / Joints
Swelling, deformity, loss of motion Gamekeeper’s / Skier’s thumb Mallet finger Scaphoid fracture vs Scapho-lunate
ligament rupture
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Provocation tests
DeQuervains: Finkelstein’s test
Phalen’s
Tinel’s
Watson’s test, pivot shift test, scapholunate ballotment test, Reagan’s test for luno-triquetral instability
CMC joint pressure/Radial and ulnar deviation