HOWTRAININGMATERIAL2010/11 SESSION2

Thehand
Clinicalassessment
A)History
Painfeltinthepalmorinthefingerjoints.Apoorlydefinedachemaybereferredfromtheneck,shoulderor
mediastinum.
Deformity appearsuddenly(duetotendonrupture)or
slowly(boneorjointpathology)
Swellinglocalized/manyjointssimultaneously.
E.g.rheumathoidarthritisswellingoftheproximaljoints,osteoarthritisthedistaljoints.
Lossoffunction
Sensorysymptomsandmotorweaknessneurologicaldisordersaffectingthelowercervicalnerverootsandtheir
peripheralextensions.

B)Examination
comparebothupperlimbs
Lookscar,colour,dry/moist,andhairyorsmooth,Wastinganddeformity,lumps,Restingposture,Swelling.
Feeltemperatureandtextureoftheskin,nodule(underlyingtendonshouldbemovedtoshowifitisattached).
Tenderness.Swelling(insubcutaneoustissue,inatendonsheathorinajoint).
Move
a)Passivemovements
rangeofmovementmetacarpophalangeal(MCP),proximalinterphalangeal(Pip),distalinterphalangeal(DIP)
joints.
b)Activemovements
Method(whatpatientneedtodo):
1. palmsfacingupwards,curlthefingersintofullflexionmayshowlaggingfinger.
2. MotorfunctionTest
flexordigitorumprofundusPIPjointimmobilizedthenbendthetipofthefinger.
flexordigitorumsuperficialisinactivateflexorprofundus
graspingallthefingers,excepttheonebeingexamined,andholdingthemfirmlyin
fullextension
flextheisolatedfingerwhichisbeingexamined
exceptions:
1st,thelittlefingersometimeshasnoindependentflexordigitorumsuperficialis
2nd,theindexfingeroftenhasanentirelyseparateflexorprofundus,whichcannotbe
inactivatedbytheusualmassactionmanoeuvre.Instead,flexorsuperficialisistestedby
askingthepatienttopinchardwiththeDIPjointinfullextensionandthePIPjointinfull
flexion;thispositioncanbemaintainedonlyifthesuperficialistendonisactiveand
intact.
longextensorsextendtheMCPjoints
MCPflexionandIPextensionsextendthefingerswiththeMCPjointsflexed(theduckbillposition).
interosseiabductandadductfinger.
Thumbmovementsfivetypesofmovement
extension(sidewaysmovementtowardsthepalmintheplaneofthepalm)abduction(upward
movementatrightanglestothepalm)
opposition(touchingthetipsofthefingers).
flexorpollicislongusimmobilizingthethumbMCPjoint.
Gripstrength
Squeezetheexaminersfingersdiminishedmuscleweakness,tendondamage,fingerstiffnessorwrist
instability.
moreaccuratelywithamechanicaldynamometer.
Pinchgripalsoshouldbemeasured.
Neurogicalassessment
ifsymptomssuchasnumbness,tinglingorweaknessexistandinallcasesoftraumaafullneurological
examinationoftheupperlimbs.Furtherrefinementisachievedbytestingtwopointdiscrimination,sensitivity
toheatandcoldandstereognosis.