MANUAL MINORS
The hand examination is a systematic clinical process used to evaluate the bones, tendons, nerves, and blood vessels for injuries or abnormalities. Given the complex anatomy of the hand, an adequate examination is crucial to detect fractures, dislocations, tendon ruptures, and nerve or vascular injuries, particularly after trauma. A thorough hand assessment allows for accurate diagnosis and timely treatment to prevent complications.
Diagnosis
Examination Step | Description |
Inspection: Deformities | Visible deformities in bones or joints may indicate fractures, dislocations, or tendon ruptures. |
Inspection: Bruising or erythema | Suggests recent trauma or inflammation. |
Inspection: Muscle atrophy | May indicate chronic nerve injury. |
Inspection: Finger posture | Abnormal finger positions may reflect flexor or extensor tendon injuries (e.g., mallet finger or boutonnière deformity). |
Palpation: Tenderness | Palpate each bone, joint, and tendon to detect specific pain points indicative of fractures, sprains, or tenosynovitis. |
Palpation: Crepitus | May suggest a fracture or joint injury. |
Palpation: Localized swelling | Indicates joint or tendon injuries. |
Mobility Assessment: Active | Ask the patient to flex and extend the fingers, thumb, and wrist to evaluate flexor and extensor tendon function. |
Mobility Assessment: Passive | The examiner moves the patient’s fingers and wrist to detect resistance or pain, indicating contractures or joint stiffness. |
Mobility Assessment: Grip strength | Ask the patient to grip the examiner’s hand, useful for detecting weakness from nerve or tendon injuries. |
Neurological Assessment: Sensation | Assess sensation in the areas innervated by the median, radial, and ulnar nerves. Loss of sensation suggests nerve injury. |
Neurological Assessment: Tinel’s sign | Gently percuss over the carpal tunnel to assess median nerve irritation; positive if tingling or pain occurs. |
Neurological Assessment: Phalen’s test | Ask the patient to flex their wrists for 60 seconds; pain or paresthesia suggests carpal tunnel syndrome. |
Vascular Assessment: Allen’s test | Evaluates hand perfusion by checking the patency of the radial and ulnar arteries. Compress one artery while the patient opens and closes their hand to observe color return. |
Vascular Assessment: Pulses | Palpate the radial and ulnar pulses to ensure adequate circulation. |
Differential Diagnosis
Injury | Distinctive Features |
|---|---|
Phalangeal fracture | Focal pain, palpable or visible bone deformity, limited active and passive mobility. |
Flexor or extensor tendon rupture | Inability to flex or extend the affected finger, often associated with trauma or lacerations. |
Carpal tunnel syndrome | Paresthesias in the median nerve distribution (thumb, index, middle fingers) and wrist pain. |
Ulnar nerve injury | Loss of sensation in the little finger and weakness in finger flexion, with visible muscle atrophy. |
Rheumatoid arthritis | Morning stiffness, symmetrical swelling of small joints, ulnar deviation, and chronic joint pain. |
Emergency Management
Initial management in emergencies depends on the findings. Fractures should be immobilised and referred for reduction or surgery if necessary. Open wounds affecting tendons or nerves require surgical repair. If nerve or vascular injury is suspected, immediate specialist follow-up is necessary. Pain management involves analgesics and anti-inflammatories.
Definitive Treatment
Definitive treatment varies based on the specific diagnosis. Fractures may require reduction or surgical fixation, while tendon injuries often necessitate surgical repair followed by immobilisation and rehabilitation. Nerve injuries require specialised neurological evaluation, and tenosynovitis is managed with NSAIDs, physical therapy, or, in some cases, surgery. Rehabilitation is crucial to restore function and prevent long-term complications.
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