CURRENT CONCEPTS

Physical Examination of the Hand

Raymond J. Kenney, MD, Warren C. Hammert, MD

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ASSH Disclaimer: The material presented in this CME activity is made available by the Learning Objectives
ASSH for educational purposes only. This material is not intended to represent the only  Discuss obtaining careful history during hand examination.
methods or the best procedures appropriate for the medical situation(s) discussed, but  List the different diagnostic tools used for examination of the hand.
rather it is intended to present an approach, view, statement, or opinion of the authors  Describe the diagnostic tests for assessing different hand pathologies.
that may be helpful, or of interest, to other practitioners. Examinees agree to participate  Detail the clinical assessment of sensory and motor functions of the hand.
in this medical education activity, sponsored by the ASSH, with full knowledge and  Outline methods of assessing musculotendinous and skeletal systems in the hand.
awareness that they waive any claim they may have against the ASSH for reliance on any
Deadline: Each examination purchased in 2014 must be completed by January 31, 2015, to
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be eligible for CME. A certificate will be issued upon completion of the activity. Estimated
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discussed or reviewed during this educational activity may not yet have received FDA
approval. Copyright ª 2014 by the American Society for Surgery of the Hand. All rights reserved.

Examination of the hand is an essential piece of a hand surgeon’s skill set. This current
concepts review presents a systematic process of performing a comprehensive physical ex-
amination of the hand including vascular, sensory, and motor assessments. Evaluations
focused on specific hand diseases and injuries are also discussed. This information can be
useful for any health care provider treating patients with hand conditions. (J Hand Surg Am.
2014;39(11):2324e2334. Copyright
2014 by the American Society for Surgery of the
Hand. All rights reserved.)
Key words Digits, finger, hand, physical examination.
Current Concepts

From the Department of Orthopaedics and Rehabilitation, School of Medicine and Dentistry, Corresponding author: Warren C. Hammert, MD, Department of Orthopaedics and
University of Rochester Medical Center, Rochester, NY. Rehabilitation, School of Medicine and Dentistry, University of Rochester Medical Center, 601
Elmwood Avenue, Box 665, Rochester, NY 14642; e-mail: [email protected].
Received for publication January 14, 2014; accepted in revised form April 15, 2014.
edu.
No benefits in any form have been received or will be received related directly or indirectly
to the subject of this article. 0363-5023/14/3911-0037$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2014.04.026

2324 r
2014 ASSH r Published by Elsevier, Inc. All rights reserved.

 PHYSICAL EXAMINATION OF THE HAND 2325

E
XAMINATION OF THE HAND is essential when car- Pertinent questions for obtaining a history of an acute
ing for patients with both acute and chronic condition include: When and where did the injury
hand conditions because an accurate diagnosis occur? What was the mechanism and energy of the
is necessary for appropriate treatment and providing injury? If a wound is present, was the environment
the patient the opportunity for the best outcome. A clean or dirty? Is there a limitation of movement and
consistent, systematic approach of hand assessment if so, is this because of pain? If there is pain, can it
should be used to minimize the chance of missing be localized to a specific area? Is there associated
important findings. As the examiner becomes more numbness and if so, what is the distribution? Did
comfortable with the process, a focused history and these occur immediately after the injury or at a point
thorough examination can be performed, which also between the injury and examination?
enable the diagnosis of other important conditions For chronic hand conditions, the questioning is
that may not be the presenting problem. Evaluation broader: When did the presenting problem begin and
of the patient with an acute injury can be more what has the course been like? What are the pain char-
challenging because the patient may have anxiety acteristics and duration—constant or intermittent? Can
regarding the injury and may have more difficulty this be localized to 1 specific location? Is there associ-
describing the details of the injury. This will often ated paresthesia, stiffness, or weakness? If so, are these
necessitate a more focused examination because always present or do they fluctuate? Are there temper-
many of the provocative maneuvers used for evalu- ature changes—warmth or cold? Are there specific ac-
ation of chronic conditions are not essential. tions or movements that aggravate the condition? Does
If the patient is examined in the office, the patient anything alleviate the symptom? How does this affect
is seated across from the examiner with the arm daily activities, vocation, and avocations?
resting on a hand table. The examination can be more
challenging in the emergency department because the Physical examination
patient is often on a stretcher. If the patient can sit up,
The examiner should be positioned across from pa-
a bedside table can often be used in a manner similar
tient, ideally with the patient’s hands resting on a
to the office. If the patient cannot sit up, owing to
hand table. The arms should be exposed to allow
possible spine or other trunk or extremities injuries,
visualization and palpation from the elbow distally.
the examination must be performed with the patient
Both extremities should be evaluated because this
lying down, either by holding the hands over the
will provide a comparison of an asymptomatic hand
abdomen or at the patient’s side.
and may enable the examiner to diagnose secondary
Before the widespread use of electronic medical
conditions.
records, documentation with diagrams and charts were
Basic items necessary for complete examination
helpful in documenting physical findings. Now we
of the hand include a goniometer and instrument to
have adopted documenting strictly with writing. A
assess 2-point discrimination. Additional specialized
consistent method for documentation is recommended,
instruments include Semmes-Weinstein monofilaments,
such as beginning with appearance, followed by mo-
a tuning fork, a dynamometer, a surface thermometer,
tion and strength, circulation, and sensation. The final
and Doppler (Fig. 1).
aspect includes special findings such as cords associ-
ated with Dupuytren disease, lesions, and so forth. Inspection/palpation: Observations include how patients
position or use their hands and the digital cascade or
resting posture of the hand. Skin color and localized
GENERAL HAND EVALUATION or generalized swelling should be noted and compared
History with the opposite extremity.
The history portion of the hand examination should Acute injury to the hand often presents with visible
Current Concepts

include general information such as age, sex, hand signs of trauma including laceration, puncture, in-
dominance, occupation, previous hand injury, and jection, burn, ecchymosis, and erythema. Scars can
preexisting impairment or conditions that may affect be clues to prior trauma or surgical interventions.
function. The history of the present problem differs Chronic skin lesions, ulcerations, nonhealing wounds,
for acute and chronic conditions. or swelling could indicate tumors or cysts.
The history should begin with open-ended ques- Inspection of the nail complex or perionychium
tions, letting patients tell their story. After listening to can reveal pitting, spots, or brittle nail plates. These
the history, it will be necessary to ask more specific findings may indicate systemic disease, nutritional
questions to hone in on more pertinent symptoms. deficiencies, or chronic nail infections.

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 2326 PHYSICAL EXAMINATION OF THE HAND

FIGURE 1: Instruments commonly necessary to complete a physical examination of the hand: A finger and B wrist goniometers used
to measure joint range of motion. C Two-point discriminator used to test sensation. D Dynamometer and E thumb pinch meter used to
measure strength. F Doppler that can be used to assess vascular flow to the hand or digits, or both.

Have patients flex their fingers and oppose the Nerve function can be evaluated with tests for
thumb, observing for normal range of motion, abnormal threshold (vibration, light touch, and Semmes-
movements, rotational deformity, or scissoring of the Weinstein monofilament) and innervation density
digits with flexion, and any limitation of full flexion. (static and dynamic 2-point discrimination). Changes
Palpate for any masses or areas of tenderness, in 2-point discrimination will occur immediately after
noting any localized swelling or redness and, if pre- a nerve laceration, but are late findings with nerve
sent, whether it is associated with fluctuance. Assess compressions. Changes in threshold tests will occur
skin temperature and compare with adjacent digits as earlier in nerve compressions and are more sensitive
well as the opposite hand. when testing for compression neuropathies.1e3
Threshold testing can be assessed by gently
Vascular system: The digits are assessed for color,
touching the patient within the defined zones of
warmth, and capillary refill in the nailbed (normal,
sensory distribution (Fig. 2). This can be completed
< 3 s). The presence or absence of palpable periph-
with a finger or fine object such as the end of a cotton
eral pulses should be noted. If pulses are not palpable
swab with the patient looking away. A 256-Hz tuning
or there is concern for a vascular injury or chronic
fork can be used to test vibratory sensation by placing
occlusion, a Doppler examination is necessary.
the end of the vibrating fork on the digit. Semmes-
Current Concepts

Listening for signal with a Doppler should elicit tri-

Weinstein monofilament testing will provide more
phasic flow through normal arteries. This can be used
objective information and is performed by a hand
to determine radial and ulnar arterial flow as well
therapist. The monofilaments are placed on the digit
as superficial palmar arch and digital vessels. If the
and pressure is applied until it bends. The lightest
vascular examination suggests the presence of a
filament that the patient can feel is recorded. A
vascular mass, additional imaging such as magnetic
normal range is between 2.4 and 4.02.1,2
resonance imaging (MRI) may be considered.1
Two-point discrimination can be performed using
Sensory: Physical examination testing for hand sen- an instrument calibrated with defined measurements
sation consists of testing the patient’s ability to of separation between the points (Fig. 3). A normal
perceive light touch and 2-point discrimination. range is less than 6 mm static or less than 3 mm

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 PHYSICAL EXAMINATION OF THE HAND 2327

FIGURE 2: A Dorsal and B volar surfaces of the hand with outlines depicting the borders of sensory innervation via the median, radial,
and ulnar nerves.

dynamic. The points should be oriented in a longi- The flexor pollicis longus (FPL) is tested by
tudinal direction on both the ulnar and radial aspects blocking the metacarpophalangeal (MCP) joint of the
of the distal digit to prevent measurement of the thumb and assessing active flexion of the interpha-
adjacent digital nerve. An unfolded paperclip or langeal (IP) joint1,4,5 (Fig. 4).
blunted electrocardiogram calipers may also be used The flexor digitorum superficialis (FDS) is
to estimate the ability of the patient to discriminate assessed by blocking the flexor digitorum profundus
between 2 points.1,2 (FDP) of adjacent digits and asking the patient to flex
the proximal interphalangeal (PIP) joint. Because the
Motor: Both extrinsic and intrinsic motor function of
FDPs have a common muscle belly (at least for
the hand should be assessed. Abnormalities in the
middle, ring, and little fingers), blocking adjacent
motor examination can result from musculotendinous
digits will eliminate FDP flexion and require isolated
problems or neurological conditions and these can
contraction of FDS. This is completed for all 4 fin-
often be differentiated by tenodesis effect. When the
gers. Weak or absent FDS function in the little finger
musculotendinous units are intact, wrist extension
can be a normal variant1,4,5 (Fig. 5).
will produce finger flexion and wrist flexion will
The FDP is assessed by blocking flexion of the PIP
produce finger extension. With loss of motion from
joint and asking the patient to flex the distal inter-
neurological injury, there will be a normal pattern of
phalangeal (DIP) joint, isolating the only muscle that
tenodesis. When this motion is altered, it indicates
flexes the DIP joint1,4,5 (Fig. 6). The extrinsic ex-
Current Concepts

a disruption of the musculotendinous units. Lack

tensors are evaluated with the hand flat on the table,
of tenodesis motion can indicate transection of the
palm down. The tendons are palpated during the
tendon or musculotendinous junction (Table 1). Dif-
following maneuvers. The wrist extensors should be
ference in motion with more passive than active
assessed with the fingers closed into the palm,
suggests tendon adhesions.1
whereas finger extrinsic extensors are assessed by
Extrinsic muscles: The extrinsic flexors are evaluated asking the patient to extend the fingers.1,4,6
with the palm up and the fingers extended, testing the The abductor pollicis longus and extensor pollicis
joint on which the tested tendon inserts. brevis are assessed by abducting the thumb away

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 2328 PHYSICAL EXAMINATION OF THE HAND

TABLE 1. Abbreviations
AP Pol Adductor pollicis
APB Abductor pollicis brevis
APL Abductor pollicis longus
CMC Carpometacarpal
DIP Distal interphalangeal
ECRB Extensor carpi radialis brevis
ECRL Extensor carpi radialis longus
ECU Extensor carpi ulnaris
EDC Extensor digitorum communis
EDQ Extensor digiti quinti
EIP Extensor indicis proprius
EPB Extensor pollicis brevis
EPL Extensor pollicis longus
FDP Flexor digitorum profundus
FDS Flexor digitorum superficialis
IP Interphalangeal
MCP Metacarpophalangeal
FIGURE 3: Examiner testing 2-point discrimination using an PIP Proximal interphalangeal
instrument calibrated with defined measurements of separation UCL Ulnar collateral ligament
between the points.

from the hand and extending the MCP joint against Intrinsic muscles: This begins with flexion of the MCP
resistance.1,4,6 joints and extending the PIP joints.
The extensor carpi radialis longus and brevis are Then, the MCP joints are extended and the fingers
assessed by wrist extension and radial deviation are abducted and adducted and the fingers are crossed,
against resistance.1,4,6 which will test the interosseous muscles. Opposing the
The extensor pollicis longus is assessed by lifting thumb to the tip of the little finger assesses thenar
the thumb up from the table. It is possible to have IP muscle function. Adducting the thumb against the in-
extension through interconnections with extensor dex finger assesses the adductor pollicis muscle.
pollicis brevis, but only an intact, functioning Intrinsic tightness is evaluated by comparing the
extensor pollicis longus will allow the thumb to be amount of IP flexion with the MCP joints extended
elevated off the table.1,4,6 and flexed. This is known as the Bunnell test and is
The function of the extensor digitorum communis, considered positive when PIP joint flexion is limited
extensor indicis pollicis, and extensor digiti quinti while the MCP joint is passively extended.1,4
muscles is assessed by having the patient lift the
fingers off the table actively and against resistance. Thumb: The thumb has motion in multiple planes.
The intrinsic muscles flex the MCP and extend the IP Radial abduction is the motion of the thumb away
joints, so the MCP joints should be extended to from the palm in the plane of the hand and is a result
eliminate the intrinsic contribution to PIP extension. of function of the abductor pollicis longus. Palmar
The ring finger is difficult to independently elevate abduction is the motion of the thumb at a 90 angle
Current Concepts

because of the interconnection (juncturae) between to the hand, into the plane of the palm. Opposition
adjacent tendons. The arm can be elevated from the is a combination of palmar abduction, pronation, and
table and strength against resistance can be evaluated. flexion. This movement occurs through the thenar
This is important because a patient may have the muscles. Circumduction is the ability to rotate the
ability to extend a finger with a complete laceration of thumb in a circular manner through radial and palmar
the tendon proximal to the juncturae as the extension abduction.1
occurs through the adjacent tendon.1,4,6
With forearm pronation, the extensor carpi ulnaris Imaging
muscle lies along the ulnar aspect of the ulna, so it is Standard radiographs should include 3 views (ante-
assessed by extension and ulnar deviation.1,4,6 roposterior, lateral, and oblique) of the affected part

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 PHYSICAL EXAMINATION OF THE HAND 2329

FIGURE 4: Examiner testing FPL function by immobilizing the FIGURE 5: Examiner testing middle finger FDS function by
thumb MCP joint to isolate the IP joint. having the patient flex the PIP joint while immobilizing adjacent
finger FDP function.

(digital views are preferred for isolated finger con-

ditions). When imaging a lateral view of the hand, the Vascular imaging such as magnetic resonance
fingers should be fanned to enable visualization of all angiography, computed tomography angiography or
fingers.7 arteriogram can be useful to define vascular anatomy
Special views of the hands are often required to and evaluate pathologic changes.8
capture radiographic images of specific portions of the
Other studies
hands that are not well-visualized on standard images.
A true anteroposterior and lateral of the thumb ray Additional studies such as electrodiagnostic ones can
to better visualize the trapeziometacarpal joint as it be used to obtain additional information for peripheral
is usually obscured in standard radiographic views of nerve conditions such as injuries or compression and
the hand.7 after repair or reconstruction of neural structures.2,9
Stress views of the thumb can be used to evaluate
either subluxation at the trapeziometacarpal joint or EVALUATION OF SPECIFIC CONDITIONS
MCP joints.7 Tendon disorders
Brewerton’s view is used to visualize erosions or Acute tendon injuries are the result of a laceration or
bony/collateral ligament avulsions of the metacarpal avulsion from the bony insertion.
heads and the bases of the phalanges.7
Current Concepts

Flexor tendon injuries can be described in 5 zones

Advanced imaging such as computed tomography based on the location of the tendon rupture using
and MRI are not commonly needed for evaluation surface landmarks of the volar hand (Fig. 7). The
of hand injuries. They may, however, be helpful digital cascade is observed. A normal digital cascade
for certain chronic conditions. Magnetic resonance has each sequential finger slightly more flexed from
imaging should be considered for evaluation of soft radial to ulnar (Fig. 8). Any disruption of this cascade
tissue masses. Computed tomography should be suggests a flexor tendon injury. Any skin disruption
considered if complex fractures or nonunion require is a potential site for a tendon laceration. Closed FDP
further assessment.7 tendon avulsions can occur and most commonly

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 2330 PHYSICAL EXAMINATION OF THE HAND

FIGURE 6: Examiner testing index finger FDP function while FIGURE 7: Volar surface of the hand with lines defining the
immobilizing the PIP joint. borders of flexor tendon injury zones I to V.

affect the ring finger. Each tendon is assessed as flaccid, but if it is disrupted the central tendon cannot
described above. If there is motion of the finger with extend the PIP joint as it moves proximally, resulting
a suspected tendon injury, strength should be asses- in the extension force at the DIP joint. This will
sed by flexing against resistance. If a substantial create a rigid joint when attempting to passively
partial injury is present, the patient will have pain, move the distal phalanx. With time, disruption of the
weakness, or inability to flex against resistance.1,4,5 central tendon will result in volar migration of the
Extensor tendon injuries can be described in terms lateral bands, resulting in a flexion force at the PIP
of 9 zones for the finger and wrist extensors and joint, creating a boutonniere deformity, which is
5 zones for the thumb1,4,6 (Fig. 9). flexion at the PIP joint and hyperextension at the DIP
Mallet fingers are injuries at the terminal tendon joint.1,4,6,12
and can occur as a result of direct laceration, closed Injuries farther proximal along the dorsum of the
rupture, or avulsion fracture. This will result in an hand are assessed by having the patient extend the
extension lag at the DIP joint. The posture of the fingers and wrist simultaneously. Any extension lag
PIP joint should also be assessed, because a patient at the MCP joint is noted. If full extension is present,
with lax palmar plate will develop a secondary swan strength is assessed against resistance because a
Current Concepts

neck deformity, which is hyperextension at the PIP digit can be extended with a completely lacerated
joint and flexion at the DIP joint.10 Standard digital tendon by pulling the adjacent tendon through the
radiographs should be performed to assess for bony juncturae.1,4,6
versus soft tissue mallet injury as this changes Acute sagittal band injuries are classified as 3
management.1,4,6 types.13 Type 1 involves a contusion without tear or
Integrity of the central tendon is assessed with instability. Type 2 involves tearing of the sagittal
Elson’s test.11 The PIP joint is flexed on a tabletop band fibers and subluxation of the extensor tendon
and the patient is asked to extend against resistance. away from the side of injury. This must be differen-
If the central tendon is intact the extensor tone is tiated from a trigger digit because the patient’s
directed at the PIP joint and the DIP joint will remain description may be the same for these conditions.

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 PHYSICAL EXAMINATION OF THE HAND 2331

FIGURE 8: Disruption of the normal digital cascade with

decreased flexion of the ring finger.

Type 3 involves tendon dislocation into the groove FIGURE 9: Dorsal surface of the hand with odd-numbered nu-
merals marking the extensor tendon injury zones. Odd-numbered
between metacarpal heads.1,4,6,13
zones are centered at the joints and even-numbered zones are
between adjacent joints.
Chronic tendon conditions
Trigger digits are caused by stenosing tenosynovitis
of the FDS tendon that results in the tendon becoming Nerve disorders
trapped within the A1 pulley. Distal stenosing teno- Acute nerve injuries in the hand are most commonly of a
synovitis affects A3 pulley and the FDP tendon.1 In sensory nature. They are assessed with light touch and 2-
the early stages there is tenderness that can progress point discrimination. A wound in the hand over the re-
to triggering with active extension, followed by gion of the median or ulnar nerves requires assessing
locking of the digit requiring manipulation and, motor function of these nerves as well. Wounds along
finally, a locked digit with flexion at the PIP joint. the dorsal aspect of the hand require assessment of the
The digit is palpated in the A1 pulley region and the sensory branches of the radial and ulnar nerves.1,2
patient is asked to slowly flex and extend the digit, There are several names associated with exami-
assessing tenderness and any triggering or crepita- nation findings following acute nerve injuries, and
tion. The digit is then passively flexed and extended they are occasionally associated with more severe
and often a nodule can be palpated.1,4,14 chronic nerve compressions.
In de Quervain tendinopathy, tenderness to pal- Wartenberg sign is an inability to adduct the little
pation along the first dorsal compartment of the wrist finger because of paralysis of the third palmar inter-
osseous muscle.1,2
Current Concepts

and sometimes in the radial styloid will be present.

Finkelstein maneuver involves flexing the thumb and Froment sign is flexion of the IP joint of the thumb
bringing the wrist into radial deviation. This may be when attempting to pinch a flat object between the
completed with the examiner holding the thumb or thumb and index finger as a compensation for
having the patient wrap the thumb with the fingers to weakness of the adductor pollicis and first dorsal
hold it against the palm.1,4,14 interosseous muscles.1,2
The intrinsic tightness test confirms the presence Jeanne sign is hyperextension of the MCP joint of
of intrinsic muscle contracture and is performed as the thumb that occurs with IP flexion (Froment sign)
described above. when pinching between the thumb and index finger.1,2

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 2332 PHYSICAL EXAMINATION OF THE HAND

Bouvier maneuver is used to assess function on

the central slip (extrinsic extensor) in patients with
ulnar nerve palsy and claw deformity. With MCP
joint hyperextension, the PIP joints cannot be actively
extended. The MCP joints are blocked short of full
extension and active PIP joint extension is assessed.
In longstanding cases, the central slip may be atten-
uated and active PIP extension may not be possible.
Chronic nerve conditions involve compressive
neuropathies. Carpal tunnel syndrome is the most
common compression neuropathy. Nighttime pain
and awakening is a common presenting report as well
as exacerbation of the numbness while driving and a
pins and needles feeling. When the compression is
advanced, the patient may report clumsiness and
difficulty holding, picking up, or feeling objects.1,2,9
The history determines the duration of symptoms,
which digits are involved, whether the symptoms are
present during the day or night, and whether the
numbness is intermittent or constant. The examina-
tion should assess light touch or threshold testing.
The bulk of the thenar muscles should be palpated
and any wasting of the APB should be documented.
The thumb is opposed to the little finger and strength
is assessed. With loss of thenar function, the patient FIGURE 10: Position of the examiner’s thumb to perform the
may be able to oppose with the ulnar innervated deep carpal tunnel compression test.
head of the flexor pollicis brevis and flex the thumb
across the palm to the little finger using the FPL
tendon. Provocative maneuvers include the following assessed for instability or anterior movement on the
tests1e3,9 (Fig. 10). medial epicondyle, which occurs before subluxation or
Phalen (and reverse Phalen) maneuver is per- anterior subluxation. Threshold testing and the ulnar
formed with the wrist in maximal flexion (extension). innervated intrinsic muscles are assessed.1,2,9
Reproduction of numbness in the median nerve dis-
tribution within 60 seconds is considered positive. Bone and joint disorders
Tinel’s sign is elicited by tapping along the median Acute bony injuries include fractures, dislocations,
nerve at the level of the carpal tunnel. The carpal and ligament injuries.
tunnel compression test is performed by applying Fractures of the phalanges and metacarpals may
manual pressure over the transverse carpal ligament manifest as deformity, angulation, rotation, swelling,
for 30 seconds. Both the Tinel’s and carpal tunnel and ecchymosis of the hand or digits. Fractures will
compression test are considered positive when the have tenderness to palpation or manipulation of the
patient feels paresthesias into the digits innervated by fracture fragments. Radiographs will be diagnostic
the median nerve.1,2,9 and obtaining 3 standard views is important to iden-
Ulnar nerve compression can occur at the elbow or tify fractures.1,15
Current Concepts

less commonly at Guyon canal. Ulnar neuropathy at Dislocations are described as dorsal, volar, or
the elbow will have decreased sensibility along the lateral with the position of the distal bone in relation
dorsal ulnar aspect of the hand owing to involvement of to the proximal. Dorsal dislocations are more com-
the dorsal sensory branch of the ulnar nerve proximal mon than volar ones in the fingers such as the PIP
to the wrist. Compression at Guyon canal will have joint and result from disruption of the collateral lig-
normal sensation along the dorsal hand. Symptoms aments and palmar plate. Radiographs will confirm
include paresthesias in the little finger as well as the diagnosis.1,15
weakness or clumsiness in the hand. Provocative ma- Ligament injuries will often result from a laterally
neuvers for ulnar nerve compression at the elbow directed force not sufficient to cause dislocation.
include the elbow flexion test. The nerve should be Palpation of the joint will often demonstrate tenderness

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 PHYSICAL EXAMINATION OF THE HAND 2333

nodes, or thumb metacarpal adduction contracture

TABLE 2. Normal Range of Motion of Digital
Joints1,20 as with arthritis at the base of the thumb. Weakness
and pain with pinch or twisting activities such as
Range of Motion removing a lid from a jar are often reported. The
Finger joint joints are palpated for prominences and motion is
MCP 45 from neutral (hyperextension) to 90 assessed. Grind (compression at the MCP, PIP, and
PIP 0 to 100 DIP joints of all digits and trapeziometacarpal joint,
DIP 0 to 80
with a shear motion) and distraction of the joint will
elicit discomfort. This must be differentiated from
Thumb joint
first dorsal compartment tendonitis.1,17
IP 15 from neutral (hyperextension) to 80
Inflammatory arthritis most commonly affects the
MCP 10 from neutral (hyperextension) to 55
MCP joints. Rheumatoid arthritis affecting the hand
CMC (basal 0 to 45 palmar adduction/abduction is much less frequent because of improvements in
joint) 0 to 60 radial adduction/abduction
medications. Ulnar deviation at the MCP joints,
which occurs as a result of synovitis and stretching of
and a mass if the ligament is ruptured. Stress radio- the capsule, with resultant subluxation of the extensor
graphs and advanced imaging, such as MRI or ultra- tendons and eventual contracture of the intrinsic
sound, can assist with diagnosis by demonstrating muscles, may be present. If the patient cannot actively
ligamentous incompetence, but are not always extend the digits, they should be passively extended. If
necessary.1,15 the patient can hold the fingers in extension, the ten-
Thumb MCP joint collateral ligament injuries occur dons are intact but subluxed. Inability to hold the
from forced deviation with resultant tearing of the fingers in extension results from tendon rupture.1,17
ligament. The ulnar collateral ligament is particularly
problematic because it can retract proximally and the Vascular disorders
adductor aponeurosis may become interposed between The radial and ulnar arteries should be palpated at the
and the bone, precluding healing. The joint is assessed wrist for diminished or absent pulse. The Allen test is
for laxity with stress test in both radial and ulnar used to qualitatively assess the contribution of blood
directed stress, both with the joint in extension and flow to the palmar arches from each artery. Occlude
flexion, and compared with the contralateral side.1,15 both arteries at the wrist and have the patient open
Finger collateral ligament injuries are assessed in a and close the fingers, tightly squeezing as the digits
manner similar to that of the thumb. The MCP joints flexed, until the hand becomes pale. Release 1 artery
may have a slightly deviated posture and stress tested and assess for perfusion of the hand. Repeat for the
in flexion whereas the PIP joints are often aligned but other artery and note any differences in the time for
present with localized tenderness and stress tested in reperfusion. Perfusion of the digits should occur in
extension.15 less than 4 seconds.18
Chronic bony conditions are generally represented Digits can be assessed in a similar manner by the
by arthritis and include both degenerative (osteoar- digital Allen test, although this is more challenging
thritis) and inflammatory arthritis. Radiographs of the because of their size. Blood flow to the palmar arch
affected part are diagnostic. Active and passive mo- and the proper digital artery can be independently
tion can be measured at each joint using a goniom- assessed via Doppler signal.
eter1 (Table 2). Acute conditions are evaluated by assessing ca-
Joint contracture is a condition in which the both pillary refill (normal, < 3 s), palpation of pulses, and
passive and active motions are limited. The contrac- listening with a Doppler flow.8
ture is caused by an intrinsic joint problem such as Compartment syndrome is a surgical emergency
Current Concepts

contracture of the collateral ligaments, whereas the and requires a high index of suspicion. This is more
joint lag is caused by an extrinsic problem such as common in the forearm but can occur in the hand
tendon adhesions. When passive motion is better than after a crush injury, closed fractures and dislocations,
active motion (referred to as an extension lag when and bleeding into closed space, and with proximal
passive extension is better than active extension), this vascular injuries after reperfusion. The hand will be
indicates an extrinsic problem such as tendon adhe- edematous and held in the intrinsic minus posture,
sions rather than a joint contracture.1,16 with MCP joints extended and PIP joints flexed.
The joints should be inspected for enlargement, Passive flexion provokes pain. The patient may des-
such as with Heberden (DIP) or Bouchard (PIP) cribe pain and paresthesias in the median nerve

J Hand Surg Am. r Vol. 39, November 2014

 2334 PHYSICAL EXAMINATION OF THE HAND

distribution or the entire hand.8 Compartment pres- Manual of Hand Surgery. Philadelphia, PA: Lippincott Williams &
Wilkins; 2010:424e432.
sure measurements can confirm the diagnosis. 9. Mackinnon SE, Novak CB. Compression neuropathies. In: Wolfe SW,
Chronic vascular conditions are evaluated in a Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative
similar manner but also may include additional Hand Surgery. 6th ed. Philadelphia, PA: Churchill Livingstone;
testing such as cold stress testing and noninvasive 2011:977e1014.
10. Tonkin MA, Hughes J, Smith KL. Lateral band translocation for
vascular studies for evaluation of vasospastic condi- swan-neck deformity. J Hand Surg Am. 1992;17(2):260e267.
tions and/or angiography for occlusive conditions.1,17,19 11. Elson RA. Rupture of the central slip of the extensor hood of the
finger: a test for early diagnosis. J Bone Joint Surg Br. 1986;68(2):
229e231.
REFERENCES 12. Littler JW, Eaton RG. Redistribution of forces in the correction of
boutonniere deformity. J Bone Joint Surg Am. 1967;49(7):1267e1274.
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nosis. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:1e160. band injuries. J Hand Surg Am. 1994;19(4):590e594.
2. Elfar JC, Petrungaro JM, Braun RM, Cheng CJ, et al. Nerve. In: 14. Wolfe SW. Tendinopathy. In: Wolfe SW, Hotchkiss RN, Pederson WC,
Hammert WC, Calfee RP, Bozentka DJ, Boyer MI, eds. ASSH Kozin SH, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia,
Manual of Hand Surgery. Philadelphia, PA: Lippincott Williams & PA: Churchill Livingstone; 2011:2067e2088.
Wilkins; 2010:294e342. 15. Baltera RM, Hastings H, Sachar K, Jitprapaikulsarn S, et al. Fractures
3. Gelberman RH, Szabo RM, Williamson RV, Dimick MP. Sensibility and dislocations: hand. In: Hammert WC, Calfee RP, Bozentka DJ,
testing in peripheral-nerve compression syndromes: an experimental Boyer MI, eds. ASSH Manual of Hand Surgery. Philadelphia, PA:
study in humans. J Bone Joint Surg Am. 1983;65(5):632e638. Lippincott Williams & Wilkins; 2010:186e215.
4. Chang J, Noland S, Adams JE, et al. Tendon. In: Hammert WC, 16. Hastings H, Watson JB, Jitprapaikulsarn S. Stiffness. In: Hammert WC,
Calfee RP, Bozentka DJ, Boyer MI, eds. ASSH Manual of Hand Sur- Calfee RP, Bozentka DJ, Boyer MI, eds. ASSH Manual of Hand Sur-
gery. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:93e144. gery. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:170e185.
5. Seiler JG. Flexor tendon injury: acute injuries. In: Wolfe SW, 17. Bernstein RA, Sammer DM, Rizzo M, et al. Arthritis. In: Hammert WC,
Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative Calfee RP, Bozentka DJ, Boyer MI, eds. ASSH Manual of Hand Sur-
Hand Surgery. 6th ed. Philadelphia, PA: Churchill Livingstone; gery. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:351e392.
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JOURNAL CME QUESTIONS

Physical Examination of the Hand Which of the following statements is most accurate
regarding hand examination?
Which of the following statements is LEAST
a. The Wartenberg sign is the inability to abduct the
accurate regarding hand examination?
little finger.
a. Tenodesis effect can differentiate between b. The Elson test assesses the integrity of the central
denervated and injured muscle.
tendon.
b. Normal capillary refill should be less than 3
c. The Phalen test is positive if symptoms are
seconds. reproduced in 90 seconds.
c. A Doppler signal should elicit a biphasic response.
d. The carpal tunnel compression test is performed
Current Concepts

d. Thumb radial abduction is the function of the by applying pressure over the nerve for 60 seconds.
abductor pollicis longus.
e. The Froment sign is extending the thumb inter-
e. Type 2 sagittal band injuries cause subluxation phalangeal joint.
of the extensor tendon over the metacarpal head.

To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home.

J Hand Surg Am. r Vol. 39, November 2014