The Hand & Wrist Exam
The Patient
Around the Room
Mobility devices, sling, brace, etc.
General Features
Age, gender, comfort, scars
Features of Cushing's Syndrome
Moon face, buffalo hump, thin skin, striae
Inspection
Skin
Rashes, sclerodactyly, Raynaud's
Swelling
Joint swelling, dactylitis
Muscle Wasting
Thenar / hypothenar eminence
Deformities
Ulnar deviation, boutonniere, swan neck, z-thumb, Heberden's, Bouchard's
Nails
Onycholysis, pitting, ridging, splinter haemorrhages
Elbows
Nodules, gouty tophi, psoriasis
Peripheral Nerve Signs
Wrist drop, benediction hand, claw hand
Sensory Examination
Radial, median, ulnar nerves
Palpation
Bony Landmarks
Soft Tissue Landmarks
Muscles
Forearm, hypothenar and thenar eminences
Wrist and Ulnar Styloid
Synovitis, effusions, ROM, crepitus
Metacarpophalangeal Joints
Synovitis, effusions, ROM, crepitus, subluxation
Proximal & Distal Interphalangeal Joints
Synovitis, effusions, ROM, crepitus, subluxation
Palms
Flexor tendon crepitus
Tests for Carpal Tunnel Syndrome
If appropriate
Tinel's sign, Phalen's test
Movement
Active → Passive
Ask before stressing painful joints
Grip Strength
Pincer Grip
Wrist Flexion
Anterior movement of the wrist
80°Wrist Extension
Radial Nerve
Posterior movement of the wrist
70°Ulnar Deviation of the Wrist
Medial angulation of the wrist
30°Radial Deviation of the Wrist
Lateral angulation of the wrist
20°Flexion of MCP, PIP and DIP joints
Closing the fist
80-100°Extension of MCP, PIP and DIP joints
Opening the hand
0°Finger Abduction
Ulnar nerve
Moving fingers apart in coronal plane
20°Finger Adduction
Bringing fingers together in coronal plane
20°Thumb Flexion
Anteriorly away from the palm
50°Thumb Extension
Posteriorly toward the palm
10°Thumb Abduction
Median Nerve
Laterally away from the hand
70°Thumb Adduction
Medially toward the hand
70°Thumb Opposition
Diagonally across the palm
70°
Functional Tests
Grip Strength
Ask the patient to make a fist and squeeze fingers
Opening a Jar
E.g. a urine jar
Key and Lock Test
Ask the patient to pick up a key, put it in an imaginary lock and turn it
Buttoning a shirt cuff
Ask the patient to unbutton and rebutton a shirt cuff