Hand Examination

Examiner Favorite

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.

Hand Examination Summary

High-Yield Exam Summary

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

Key Concept

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)

movement	normalRange	technique	keyPoints
MCP Flexion	0-90°	Make a fist	Compare each finger
MCP Extension	0-30° hyperextension	Flatten fingers on table	Varies by laxity
PIP Flexion	0-100°	Bend middle joint	Test each finger
DIP Flexion	0-80°	Bend tip joint	FDP integrity
Thumb Opposition	Touch 5th MC base	Touch thumb to little finger base	Thenar function
Thumb Abduction	60° from palm	Lift thumb perpendicular to palm	APB function

Special Tests

Flexor Tendon Integrity

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

Sensitivity100%

Ability to detect true positives

Specificity100%

Ability to exclude false positives

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

Sensitivity100%

Ability to detect true positives

Specificity100%

Ability to exclude false positives

Extensor Tendon Integrity

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

Sensitivity100%

Ability to detect true positives

Specificity100%

Ability to exclude false positives

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

Sensitivity87%

Ability to detect true positives

Specificity93%

Ability to exclude false positives

Intrinsic Function

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

Sensitivity90%

Ability to detect true positives

Specificity90%

Ability to exclude false positives

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

Sensitivity95%

Ability to detect true positives

Specificity95%

Ability to exclude false positives

Nerve Function

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

Sensitivity90%

Ability to detect true positives

Specificity98%

Ability to exclude false positives

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

Sensitivity85%

Ability to detect true positives

Specificity96%

Ability to exclude false positives

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

Sensitivity96%

Ability to detect true positives

Specificity97%

Ability to exclude false positives

Other Tests

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

Sensitivity75%

Ability to detect true positives

Specificity97%

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

Must Know

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

VIVA SCENARIOStandard

Presenting Your Findings

EXAMINER

"65-year-old woman with progressive hand deformity and difficulty with daily tasks."

KEY POINTS TO SCORE

Describe deformities using correct terminology

Note symmetry of findings (asymmetric = consider other diagnoses)

Assess functional impact

Look for extra-articular features

COMMON TRAPS

✗Missing subtle intrinsic wasting

✗Forgetting to test FDS to each finger

✗Not distinguishing tendon from joint pathology

✗Missing carpal tunnel syndrome in RA

Common Conditions Table

condition	look	feel	move	specialTests
Rheumatoid Arthritis	MCP/PIP swelling, deformities	Synovitis, warmth	Reduced grip	Specific deformity pattern
Osteoarthritis	DIP Heberden's, PIP Bouchard's	Bony enlargement, no warmth	Stiff but functional	First CMC squaring
Dupuytren's Disease	Palmar nodules, cords, contracture	Firm cords in palm	Finger extension limited	Hueston table-top test
Trigger Finger	May be normal	A1 pulley nodule	Triggering, locking	Palpable click on flexion
Ulnar Nerve Palsy	Guttering, claw hand	Sensation loss ulnar 1.5 digits	Weak grip, pinch	Froment's +, Wartenberg's +

Examiner Tips

Scoring High in the Hand Examination

High-Yield Exam Summary

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

Hand Examination

Examiner Favorite

Hand Examination Summary

High-Yield Exam Summary

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

Key Concept

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)

movement	normalRange	technique	keyPoints
MCP Flexion	0-90°	Make a fist	Compare each finger
MCP Extension	0-30° hyperextension	Flatten fingers on table	Varies by laxity
PIP Flexion	0-100°	Bend middle joint	Test each finger
DIP Flexion	0-80°	Bend tip joint	FDP integrity
Thumb Opposition	Touch 5th MC base	Touch thumb to little finger base	Thenar function
Thumb Abduction	60° from palm	Lift thumb perpendicular to palm	APB function

Special Tests

Flexor Tendon Integrity

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

Sensitivity100%

Ability to detect true positives

Specificity100%

Ability to exclude false positives

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

Sensitivity100%

Ability to detect true positives

Specificity100%

Ability to exclude false positives

Extensor Tendon Integrity

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

Sensitivity100%

Ability to detect true positives

Specificity100%

Ability to exclude false positives

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

Sensitivity87%

Ability to detect true positives

Specificity93%

Ability to exclude false positives

Intrinsic Function

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

Sensitivity90%

Ability to detect true positives

Specificity90%

Ability to exclude false positives

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

Sensitivity95%

Ability to detect true positives

Specificity95%

Ability to exclude false positives

Nerve Function

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

Sensitivity90%

Ability to detect true positives

Specificity98%

Ability to exclude false positives

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

Sensitivity85%

Ability to detect true positives

Specificity96%

Ability to exclude false positives

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

Sensitivity96%

Ability to detect true positives

Specificity97%

Ability to exclude false positives

Other Tests

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

Sensitivity75%

Ability to detect true positives

Specificity97%

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

Must Know

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

VIVA SCENARIOStandard

Presenting Your Findings

EXAMINER

"65-year-old woman with progressive hand deformity and difficulty with daily tasks."

KEY POINTS TO SCORE

Describe deformities using correct terminology

Note symmetry of findings (asymmetric = consider other diagnoses)

Assess functional impact

Look for extra-articular features

COMMON TRAPS

✗Missing subtle intrinsic wasting

✗Forgetting to test FDS to each finger

✗Not distinguishing tendon from joint pathology

✗Missing carpal tunnel syndrome in RA

Common Conditions Table

condition	look	feel	move	specialTests
Rheumatoid Arthritis	MCP/PIP swelling, deformities	Synovitis, warmth	Reduced grip	Specific deformity pattern
Osteoarthritis	DIP Heberden's, PIP Bouchard's	Bony enlargement, no warmth	Stiff but functional	First CMC squaring
Dupuytren's Disease	Palmar nodules, cords, contracture	Firm cords in palm	Finger extension limited	Hueston table-top test
Trigger Finger	May be normal	A1 pulley nodule	Triggering, locking	Palpable click on flexion
Ulnar Nerve Palsy	Guttering, claw hand	Sensation loss ulnar 1.5 digits	Weak grip, pinch	Froment's +, Wartenberg's +

Examiner Tips

Scoring High in the Hand Examination

High-Yield Exam Summary

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

Hand Examination

Hand Examination

Quick Reference One-Pager

Hand Examination Summary

Look

Feel

Move

Special Tests

Introduction and Setup

Before You Start

Look (Inspection)

Feel (Palpation)

Systematic Palpation

Move (Range of Motion)

Special Tests

Flexor Tendon Integrity

FDP Test (Flexor Digitorum Profundus)

Technique

Positive Sign

Indicates

Diagnostic Accuracy

FDS Test (Flexor Digitorum Superficialis)

Technique

Positive Sign

Indicates

Diagnostic Accuracy

Extensor Tendon Integrity

EPL Test (Extensor Pollicis Longus)

Technique

Positive Sign

Indicates

Diagnostic Accuracy

Elson's Test

Technique

Positive Sign

Indicates

Diagnostic Accuracy

Intrinsic Function

Intrinsic Tightness Test (Bunnell)

Technique

Positive Sign

Indicates

Diagnostic Accuracy

Intrinsic Function Test

Technique

Positive Sign

Indicates

Diagnostic Accuracy

Nerve Function

Froment's Sign

Technique

Positive Sign

Indicates

Diagnostic Accuracy

Wartenberg's Sign

Technique

Positive Sign

Indicates

Diagnostic Accuracy

OK Sign (Anterior Interosseous Nerve)

Technique

Positive Sign

Indicates

Diagnostic Accuracy

Other Tests

Allen's Test

Technique

Positive Sign

Indicates

Diagnostic Accuracy

Neurovascular Assessment

Detailed Nerve Testing

Complete the Examination

Summary Presentation

Presenting Your Findings

Common Conditions Table

Examiner Tips

Scoring High in the Hand Examination

Do

Don't