Hand Examination
Hand examination tests detailed anatomical knowledge. Examiners expect you to systematically assess skin, tendons (flexor and extensor), nerves, joints, and function. Common scenarios include rheumatoid arthritis, nerve injuries, and tendon pathology.
Quick Reference One-Pager
Look
- Deformities (swan neck, boutonniere, Z-thumb)
- Muscle wasting (thenar, hypothenar, interossei)
- Skin changes (scars, nodules, callosities)
- Nail changes (pitting, clubbing)
Feel
- Temperature and sweating
- Finger pulps (sensation)
- Joints (swelling, tenderness)
- Tendons (thickening, nodules)
Move
- MCP flexion 0-90°
- PIP flexion 0-100°
- DIP flexion 0-80°
- Thumb opposition, abduction
Special Tests
- FDP: Isolate DIP flexion
- FDS: Hold other fingers extended
- Intrinsics: MCP flexed, extend IPJ
- Froment's: Pinch paper test
Introduction and Setup
Before You Start
Patient Positioning: Seated opposite examiner with hands resting on table, palms down initially
Exposure: Both hands and forearms exposed
Consent Script: "I'm going to examine your hands. I'll look at both, feel the joints and tendons, and test the movements and strength. Please tell me if anything is painful."
Key Concept: The hand is a complex integration of:
- Bones (27 per hand) and joints
- Extrinsic muscles (forearm) and intrinsic muscles (hand)
- Three major nerves (median, ulnar, radial)
- Specialized skin (palmar vs dorsal)
Look (Inspection)
- Swelling: MCP (RA), PIP (OA Bouchard's, RA), DIP (OA Heberden's)
- Deformities: Swan neck (PIP hyperextension, DIP flexion), Boutonniere (PIP flexion, DIP hyperextension)
- Muscle wasting: Interossei (ulnar nerve), thenar eminence (median)
- Skin: Scars, rheumatoid nodules, psoriatic plaques
- Nails: Pitting (psoriasis), clubbing, splinter hemorrhages
- Alignment: Ulnar drift at MCPs, rotational deformity
Classic Deformities in Rheumatoid Arthritis:
- Swan neck: PIP hyperextension + DIP flexion (FDS rupture, intrinsic tightness)
- Boutonniere: PIP flexion + DIP hyperextension (central slip rupture)
- Z-thumb: MCP flexion + IP hyperextension
- Ulnar drift: MCP joints deviate ulnarward
Feel (Palpation)
Systematic Palpation
Joints (Each finger, thumb):
- MCP joints: Dorsal swelling (synovitis), lateral squeeze test
- PIP joints: Fusiform swelling (RA), bony enlargement (OA)
- DIP joints: Heberden's nodes (OA), mucous cysts
Tendons:
- Flexor tendons: Nodules, triggering, crepitus
- Extensor tendons: Integrity, subluxation
- A1 pulley: Tenderness at MCP level (trigger finger)
Nerves:
- Tinel's: Carpal tunnel, Guyon's canal
- Digital nerves: Pinprick sensation
Other:
- Temperature: Compare hands
- Sweating: Absent in nerve injury
- Pulses: Radial, ulnar, Allen's test
Move (Range of Motion)
- normalRange
- 0-90°
- technique
- Make a fist
- keyPoints
- Compare each finger
- normalRange
- 0-30° hyperextension
- technique
- Flatten fingers on table
- keyPoints
- Varies by laxity
- normalRange
- 0-100°
- technique
- Bend middle joint
- keyPoints
- Test each finger
- normalRange
- 0-80°
- technique
- Bend tip joint
- keyPoints
- FDP integrity
- normalRange
- Touch 5th MC base
- technique
- Touch thumb to little finger base
- keyPoints
- Thenar function
- normalRange
- 60° from palm
- technique
- Lift thumb perpendicular to palm
- keyPoints
- APB function
Special Tests
Flexor Tendon Integrity
Special test
FDP Test (Flexor Digitorum Profundus)
DIP flexion and FDP integrity
Technique
- 1Stabilize the middle phalanx by holding PIP joint in extension
- 2Ask patient to bend the tip (DIP) of the finger
Positive Sign
Inability to flex DIP joint
Indicates
FDP rupture or laceration (Zone 1 or 2)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
FDS Test (Flexor Digitorum Superficialis)
PIP flexion and FDS integrity
Technique
- 1Hold all other fingers in full extension (blocking FDP action)
- 2Ask patient to flex the PIP joint of the tested finger only
Positive Sign
Inability to flex PIP joint in isolation
Indicates
FDS rupture or absence (note: FDS to little finger absent in 20%)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Extensor Tendon Integrity
Special test
EPL Test (Extensor Pollicis Longus)
Thumb IP extension integrity
Technique
- 1Hand flat on table, palm down
- 2Ask patient to lift thumb off table (retropulsion)
Positive Sign
Inability to extend thumb IP joint or lift thumb
Indicates
EPL rupture (common after distal radius fracture, RA)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Elson's Test
Central slip integrity (early boutonniere)
Technique
- 1Flex PIP to 90° over edge of table
- 2Ask patient to extend PIP against resistance
Positive Sign
DIP becomes rigid and hyperextends (lateral bands sublux)
Indicates
Central slip rupture (developing boutonniere)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Intrinsic Function
Special test
Intrinsic Tightness Test (Bunnell)
Intrinsic muscle tightness vs joint contracture
Technique
- 1With MCP extended, flex PIP passively
- 2Then with MCP flexed, flex PIP passively
- 3Compare range of PIP flexion in both positions
Positive Sign
PIP flexion less with MCP extended (intrinsics tight)
Indicates
Intrinsic muscle tightness (spasticity, ischemic contracture)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Intrinsic Function Test
Lumbrical and interosseous function
Technique
- 1Hold MCP joints in flexion
- 2Ask patient to extend IP joints (straighten fingers with MCP bent)
Positive Sign
Inability to extend IP joints with MCP flexed
Indicates
Intrinsic weakness (ulnar nerve for 4th/5th, median nerve for 1st/2nd lumbricals)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Nerve Function
Special test
Froment's Sign
Ulnar nerve motor function
Technique
- 1Patient holds paper between thumb and radial side of index finger
- 2Examiner attempts to pull paper away
- 3Observe thumb IP joint
Positive Sign
Thumb IP flexion (FPL substitution for weak adductor pollicis)
Indicates
Ulnar nerve palsy (adductor pollicis weakness)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Wartenberg's Sign
Ulnar nerve function
Technique
- 1Ask patient to hold fingers together, extended
- 2Observe little finger position
Positive Sign
Little finger remains abducted (cannot adduct)
Indicates
Ulnar nerve palsy (weak 3rd palmar interosseous)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
OK Sign (Anterior Interosseous Nerve)
AIN function
Technique
- 1Ask patient to make an 'OK' sign (thumb to index finger circle)
Positive Sign
Flat circle rather than round (loss of IP flexion)
Indicates
Anterior interosseous nerve palsy (FPL, FDP to index weakness)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Other Tests
Special test
Allen's Test
Arterial patency
Technique
- 1Patient clenches fist while examiner occludes radial and ulnar arteries
- 2Patient opens hand (palm pale)
- 3Release one artery at a time, observe color return
Positive Sign
Delayed or absent color return (greater than 5 seconds)
Indicates
Arterial occlusion or inadequate collateral flow
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Neurovascular Assessment
Detailed Nerve Testing
Median Nerve:
- Sensory: Tip of index finger (most reliable)
- Motor: Thumb abduction (APB) - "Point thumb at ceiling"
- APB test: Resisted palmar abduction
Ulnar Nerve:
- Sensory: Tip of little finger
- Motor: Finger abduction (1st dorsal interosseous)
- Test: Spread fingers against resistance
Radial Nerve:
- Sensory: First dorsal web space
- Motor: Wrist and finger extension (assessed at wrist level)
- Rarely tested in isolated hand exam
Two-Point Discrimination:
- Normal: less than 6mm at fingertip (static)
- Use paper clip or calipers
- Tests for nerve regeneration quality
Complete the Examination
Always state to the examiner:
"To complete my examination, I would like to:
- Examine the wrist as the proximal joint
- Examine the elbow and shoulder
- Perform cervical spine examination for referred symptoms
- Assess function (grip strength, key pinch, tripod pinch)
- Obtain X-rays of the hand if indicated"
Summary Presentation
“65-year-old woman with progressive hand deformity and difficulty with daily tasks.”
Common Conditions Table
- look
- MCP/PIP swelling, deformities
- feel
- Synovitis, warmth
- move
- Reduced grip
- specialTests
- Specific deformity pattern
- look
- DIP Heberden's, PIP Bouchard's
- feel
- Bony enlargement, no warmth
- move
- Stiff but functional
- specialTests
- First CMC squaring
- look
- Palmar nodules, cords, contracture
- feel
- Firm cords in palm
- move
- Finger extension limited
- specialTests
- Hueston table-top test
- look
- May be normal
- feel
- A1 pulley nodule
- move
- Triggering, locking
- specialTests
- Palpable click on flexion
- look
- Guttering, claw hand
- feel
- Sensation loss ulnar 1.5 digits
- move
- Weak grip, pinch
- specialTests
- Froment's +, Wartenberg's +
Examiner Tips
Do
- Test each tendon systematically
- Know intrinsic muscle innervation
- Assess cascade and rotation
- Test two-point discrimination
- Comment on function
Don't
- Forget FDS is absent in 20% little fingers
- Miss subtle interosseous wasting
- Confuse boutonniere and swan neck
- Ignore the thumb
- Forget Allen's test pre-operatively